Mecklenburg_Well Abandonment_20241014 (9)

WELL ABANDONMENT RECORD For Iracnial Usd ONLY..
This form can be used Ibr site or ntulliple.wills
1.Welt ContlAetor infot'nlation: W.LL ABANDONMENT Dr'TALI.;
Robert Miller 7a.iNu tuber ofvvetls bring abandoned: 1
Ll`e1t'CoulrecforNmuir(orxrlluxc pgonaByati�mtanhi;xullonhisliterprulxrtyl For warlop& fiVedion ter rlou mfer srrh*, +relit ONLY walo the s-tw
• cmurnrctrai+a�6rnnkulr+l�*rlf,iriro rue srafuiUt ewc._jb i.
2675-A' k
t4cwa Cbniraaorcaif=601i Nmitbcr
7b.Approximate volume of ovate n n hig in
sAEDAcco FOR WATER. ONLY.
Cangatq'Namc 741)- eoPdLwinlectantusetl:
2.Well Construction Permit 9-70001218,_,
I11 tall rrtrtr<lamhte netllaermiis(i.e_CawuhS Stele,l'uriume,firJac4ivar eic l fkzmwn 7d.Amount of tllsinf&i"t used:
3.well use(check well usc)s
Water.SupplyWell; 7c SeaiingtnatcrialsGse+1(cltec[�allphatapplr):
17gricult(tfat 176ltinicip t11Ptt61ic m Ncat Ccmcn(.Grout- i . la peraonitc Chips or Pcilcts,
QC=111cnnal(4601 1 C'ootino Supply) [I tesidentint Watcr Supply(single) ❑Sand Cement Grout 17 Dry•Clay -
❑bulusI Womnics:14 Oltcsidenthil Water Supply'(shh.red) 11 Couelele Gmult J3 Drill Cittiittgs
-❑hrri •tion ❑SpeeiAy Grout 13 Gravel
Non-Water Supply Welt:' -- --— in 13entonite Slurry ❑Other{ex'plain under 7g)
Q9149aai[tariarg 17Recovely..
Injcction Well: X Dior each tuatetial selected above,provide amount of.ntatexi.*t6ed:
l7Aquiferttechatge: 13GrottiuivVderRerncdi3lian Neat Ce3ai::94lb. ,Wtr:7gal. I Sand Cem.:lb ,Wtr:gal.
OAquifer.Stamge and Recovery 1jSalinity Barrier. "
❑Aquifer Test []Slanmvater Drviriage
-1313—Verirnetital Technology OSubsidence Corptttl 7g Provide a brli-f dcuriptian of the alliatLdbument P"VcMarc
OGeothemtat(Closed Loop) OTracer
1;
Tremie.grouted with portland 'cement from the bottom to
®Geothermal(HeatinWCtiolin Retum) 00thei'(c_\ lain untter Z9)
ground surface.- F
d.Datcncll(s).uband0 d: 9/23/24 y v ,_' '; S"l�''�•
T
ia.Well lucatiitn: I' Or
=r,
Pine island Country Club' sj
FacilityiewturNamc Bac!MyW9 irapplkablc) S:Cerdtirnlioit;
1701 Stoneyridge Dr. Charlotte, NC 28214 �9/30/2024
Physical Adduce.City.mid Zip
tt :"va r D rte
I _
Mecklenburg 03139101 Jfje sig»ing skis faun,J hereby certify that the wellfsl teas hoer)abandoned in .
County Farrel lit:WftC�dnnNo.(PIN) trrxrikfrrm.a with I5A ACiIC 02C,0100.or2G.6200 Meff'Conslniction Strinrkrttls
mid dni r a crop}•of this retard kas•beisa provided(.ilia treff onager.
A,Usitude and longitude in tte(m esbuirtuteAcconds or decimaldegrees:
(if%�vll raid,ow -9•Site diagram or additional cell dendLs:
You ma}use the back of this.pdge to,pin &'addilitinal ws fl site details or yell
N W. .aboudoiunerd details..You may also altaiih additional pages if lfeteMj._%,_.
�i
C()N4TRi1&ION.DFTAIL,C or WGL[.t5)BPINC ABANI]ONED SUBRfiTTAi.i MUMOM
:titurlr nail cv�rtrlrttc7rort n!iv�dfsl 1j atrcYJlrbk_ l�av irrrtltiprr ilfactiurz'W rsin-uwlir srgtplY '_
melds ONLY with I&I same rwrsrrjeoox2r arri"0161011.3aa tun smbuif{areloner ' IOa. For All,Wells: Submit-this farrit ttiithiu 30 days of completion of vvcll
6a.Well ID#.MW—BR abandonmcht to Ihc'tatlowing: I'
i
Division of WaterResaurces,information Piuemsing Unit,
6k Total tve 34,.7 ) IGi7 Dlail Suvicc Ccn�i�,Ralclllli,ltC 27fr99-1617
fl depth: (fp.
10b.ror-Inlecll n Wells; In addition to sending the forni to the address ht'10a
abovte,also submit We copy'of this foinr within'30 days of completion of v%ell
fir.Borehole diameter:2 (in.} a b uadomrteid to the folloviuy.
i, I
Divis[on of Water Rcsouries;UndcrY;rouud i►ijectiou Control Prmgram,
fad.Watcr level.betaw ground surface: (frJ 1636 lltml Scrvicc Ccntei,,Raleigh,l'iC 276_99.1636
�l
Gc Uutcr casing Icnth(if Imtrvs'n)• (fL) 10c.roe Water Strtinh,�.iirlerttno t4'ells: In addition tondinR the fomt to
tile-address(es) aboE.'e. also submit bne copy of this form within 30 days of
completiod-of well abandamnent to ttie'lcoanty health dcpuitnicid of the county
vsbcrc abandoned, ;
6L Inner easiu•,:ftubing teat vfh(if h*uwn): (ft.) 1
ft Screen length(if Immin): M.)
Form GN-30 Nonh Cmatirn Delmmnew of Ent•iranmenl nisi Natural Resow2cs—Division of WaterResoaR n Revised August 2013
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