Mecklenburg_Well Abandonment_20241014 (10)

WELL ABANDONMENT RECORD For lnlarttalUscONLY:
Thii foim can be used for single orniililpfe){t lls
1.Well Cvntractua t"Mortnatiour Y1'P.LL ARANDONh1RNT,DETAtL
Robert miller 7:.Number ofircllsbeingabandoned: 1
`VeltCondeaclorNanie{or:trllnae p�6anallyatiamtonira;:�cil.anldstl�rpiape>9y) Fm i4g1ople Nfertrar .or twimmfor sarp'rh- wells ONLY 'wifij t1n .some
rnruarrceaa•aBmP<fwivaeraf,}nn cme mbilor wit i a,
2675-A.
7b.Aliprnmate wtlume of teat ^ret in
14C15 sl
's1l Caniraaort:edir=U01%Numb itaitiinger t'
sAeDAcco FOR WATERSPI PLYNYF:LL S QN1,,Y;
J,
Cong�anq Namc lc.T_3•.e rif disinrivtant usetl-
2:Well Construction Pernilt 9-70001218,
Lid afl app,hwLle tivfllaraaitr(le.County,Srp i,1'urlmxr•Lrjactr'an;etc)►fk wW!j 7d zXtnAltlttt of disinfectant'used:
3.Well tisr(check well use),
Water Supply Well: 7a.Scaling milteri:tla:uscd(chccli all it%nt apply);'.
i]rt ultittal [71w9unisipalaPuh[ic- M Naai Ccmcat.G"t p 13 19dtitonitc Chips orPclicls
E30cothcni l(ScatinglCaoline,Siipply) : 171tcsidcut.tl Watcr Suppb-(single) ❑Sond tinitaut Grout ❑Dry Clay
❑Inddsltial/Commceci d ❑Itesidetdi,3[Watcr Stipptg:(ahtuetl)- .ConcrcEe Groin Cl Drill Cytllinl s
❑Irti thou ❑Specialty Grant ❑Gratel
Non-Water Supply 1#04 ❑.ltentonite Slurry i, ❑Other(esplain'under 7g)
QBMuaitothte: ❑Recovery'. ;
tnjcction 7f,For each ttiateriltl selected abo�r,piv%ide antontgt of matesiats ukd;
❑Aquiferltcchar),e [7Grotiiidrs Uer-Remettialimr Neat Cem.:941b ;Wtr:7gal.. + Sand Cem.:lb',Wtr:gal.
❑Aqui fei Stange turd Remvety i]S:tlinih,nonier
❑Aquifer Test ❑Stonmater.Draittage
OF-Vei interital Techuotogv LiStttisidet>;t Cotdtnl 7>r PcovEdc u bricf'itcscriptian of the alrandpnnicnt prgccduit:
Meothennat Dosed Loop) ❑Tracer
Tremie.grouted with portland.cement froin the bottom.to
DGeotherniat(ieittiomtoaGn Return) C 0t ierte-N laitiunder 7 )
ground surface. I`
4.DafettcU{sJ altandonetf. 9/23/24'
5n.Well location:
Pine Island Country-Club - 14
Facilit}lthVmr Nurns Facility tlts(fapriliwblc) 8:Certificaflmt;
1701 Stoneyridge Dr. Charlotte, NC,28214
Physical Addms City.and Zip Styli.'t�•" a?:`s. "t•"' ,' 5
>..,..;�, t�.''n-eti s�:•rsr Ulu:
Mecklenburg- 03139101 13y si},72lrtg This forma,-1/mby cerd,6y,durt the trellis)was pmrej ahandoned in
C�autsiy Pcuucl ldcruiticitliru Na.(PIN) ticwrdrurce irtllt Fi:Y.r CiiC._p?C,UI00.i r 2C.(200 Wvfi:Gaais'huclian Slawkie ds
and Ilral a wp}r offiris recarvl hm•baeii p6ided fo 11re well ouster.
5h.Latitude and 166gitudo In(!egrccstbd"tcs/sccandsbe decimal degrees:
(Ifo•011 rhW,014.,41t11ong i}4100c11) ?.:Site diagram or additional welt don.Its:
Yoti tuag'tse.tlie barb of this page to.piovide-additianat ivel(site details or Well
N - W .abatidoinitema deiails:.Yi�u«uty also attach ndditionaCpagzs if ttecessaty..
C(1N51 itiiC'fiON Dif 1AtLR n[P tl'EI i tS►RH INC:AB 1NDt1NRD SURNMEAUT,tNRTRUCTfONS
rttfut>'r u;dl cvrivttaclku!rai_vrilfs)if ovulla�la. Fid nrulnple itfjttii'iun'w•rvan•uvarr.wt�plp �I
nr"ikrONLY-iaiAIlk,mmerwistrcrfimra5oirrhumi�rat•irrnennzaabaiiltwrsfunir. lll;►..'Far eUl LM'cllc; $uhtnif tbts forrii%xithin+0 days;of completion-of well
68.1Ye1171}fi':MW-9R abandaamcttt t0'the'�all6{FIitG; j .
Division of Wutcr Rrsout�rr�i,InfotuutUon Proc��ciin);Quit,
20:it iG1711faii Scrt�cc Ccritcr;Italcid6,NC,27G'J9-16t7
6k Totalivell depth:
14b.ror ih ledlon Wells-.In addition to sending the forniLto the addiesi in.10a
6c.#latcltole dian)etew 2 (in.) abam tilso submit oud bopy of this form«ifiiu 30'days of"comptetioti of vwu
abindonuma tti Elie fallatsing:
Division of Water Resourc6,'Und rrround Injection CottttvPPrdgratu,
6d.Watcr'tet•el.belotw ground Surface:. (fiJ
1636 NUB Scnicc Center,Raleigh,NC 23619-1636
Quter,casing ten (if lat!tttt)• (fw) loc.Fnr•W;Rter�mnh'A L: lierrion t1'ells; In addiGan'to shinning the font to
6c
g �( _the address(es) above. also-submit one copy of this tbtitt wit hin.30 O s of
completion-af well ahnndoitment to the;colony health dcpanntctd of the county
6f.inner casinWtubbig,tenjIth(if lam vu): (ly) tc7tcrr abandancd,
6n,Screen length(If known): (ft)
Fomt GUI-10 North Camtlm Deporumul afEnvimuuunl and Natural Rcsouncs-Division of Wateritesoank s Revised A ra uu 2013
I'
II +.