Mecklenburg_Well Abandonment_20241014 (11)

AVLLL ABANDONMENT RECORD For trdomal(Ise ONLY;
Tbis%f n can be used for single or ntpltiple lsclls
1,Weil Coutrnett r information: )VE.LL ARANDONdiENT'DETAIL.4
Robert Miller 7a.Nwnberofhellsbebrgahandianeil: 1
t�rc]fCoutmngrNanre{rirtticllo�ia�pc6anally ilaaminning«etl.onlgsll�trprapcny) Ru• wg1tiple. nVtelion a• 69iminfer siip�ly wells' ONLY will) the same
c+aeasfrtrcfmra.ubrarnhNnaic�rat,3rrn cmr.snbainf'aa�ab�r.
2675—A
NC tiVctl Gbnl>aaorCvitlftratioti Nnirber 76.Approximate vAlume artist,r rrnu)iuiug in itell(s):
sr,EDAcco FOR WATIERSUPPLYWWELLS QNL.Y:
Caa�aatq Nams 7e.T}titc of dlslnfiYtaat fixed:
2.Well Construction Permit .-70001218,: ___- ---_--_ -_-_ ,---- ---
ListalluplaflimLleurllpurrntx,(i.ctCurarh;S&ate,t'uriruacr,Laecfioar„ctctffdamrsn 7d:a�IllOtltltafdlSltlfCelsint�U3l'd'
3.Well Use(0 1*Well use):
Water.Supply Well: 7c.Scaling matcrios,used(cbcd alltlliatapply): -
AetgricultUml ❑hlunicip,•d/Pubtic• Do Ncat Ccmctit.Grout ❑Qcroonitc Chips orPcllcts
QCiCAtljcrm tl(Hsatinn-J�:aoliuo Supply) 131icsiilcntial Water$tlpply'(single}- ❑SamlfietneW Gtnut ❑Dry Clay
❑htdustriat/Commcrcial ❑PWdential Wntcr Supply-(Oii r j ❑Condrete Grout Aj Drill Cutlin_g�
❑irri lion b Specially Groul ❑Gravel
Ron-NYater Supply Well: 13 Bentouite Slurry 0 Other(explain under 7g)
amanitoring, ❑Recavew..
Injection'Yc[lp 7r.For each utaterial selected"aboye.pi m ide autoulit-af titatcdills ttscd;
❑Aquifcr)tcclulrge. ❑GwuSrdttinterRentediation Neat Cem.:941b ,Wtr:7gal. "Sand cem'.:1b ,Wtr:gal.
13Aquifer.Storage surd ReLori.cq OSaliniti�Banier
❑Aquifer Test ❑Stiaetmcater.Drahiage .
13E1aetintecuel Technotogy. OSubsidetxe Colritol -description of thu111 -lure:7gF rh C
MGeotltennal(Closed Loop) . ❑Tracer 1'
Tremie.grouted with portland.centent from the bottom to
Mothennat(iieittiflglCoali •Return)• " ®Otlterto lain uinier 7g)
ground surface.
4.Date 9/23/24'
sa WeRtaca(ion: 'OCT, 1 < 2024
Pine Island Country Club R .�
&.Ccrti(tcation; Ir,�.;,�,::v 'c�*, a, < � tlkt
1Facilitg/thsncr Ntoa� Fatlit}LDM ffapplicablc) •�
L`rNti.u�r_•
1701,Stoneyridge,Dr. Charlotte,' NC.28214 9/30/2024
Physical Address,City,and Zip Sigh:/._ j r:rs:' `;a?,•:�:kt.. sn r U ue
Mecklenburg 03139101 By.signing lh+s•fain; 1Immby cerdfV that the erell{st bras mere}ahandatlerl ill
Canuty Parcel ldmgir5eathtu No.(PIN} rarrvnI mte trill,I'm'VoiC 02C,0100.irr 2C.:0260 Melt Gor'aslructiun 5timrhai cIs
' rnirl that a cnp}�ofllris rseaord husbEeta pinti�ided to 1ks trett ornaer,
5b,Latitude and longitude In ttcgrresrtotlatutcPlscmnds or decituai degrccsi 'I
<I1nen raid,ntte LiOnfigissttrriciicq) 7.Site diagram or additionaln'ell deritils;
You mq ts_e the ba&of tltis.page to.pitii ide additional rs�ll sitg details or trell
1: W abnndoiunett darails..'you may Ao attack aslditiotral pates if necessary.
CONCTRUMON DMA►MS OF WELL(S)BEING ABANDONED SURhiMAL tNSTRUCTfONS �
Mach trell cnaa"cildri mrurd(s)if,aV6J1rl✓la. 1-or arnlople lalecfioai or min.ttxti&.xapplP
n-�lds ONLY u•af.0 rla3 }err,rnn nrLmi,cure ji nrL i0;1;For AII'Wells: -Submit•tlti_s form within 30 day of compictian of hell
6a.Well IDAY:MW-11 abaddoumcut to the'fallol iNq;
I.
Dhision of WaterResiturrm',Information-Procewdag Unit,
37.6 1617 abil Ser icc'Ccatcr;Rulciah,NC 27G9R-1617
6b.Total well depth:. (ff.)
10b.F00h i Ilon Weals: Li addittoq,to sending the form to►be addrMs to 10a
abort,;also subnth one copy.of this foiai►�tiitldu 30 days of completion of v.ill
6c.Borehole dtametew 2 {in.} abiindomrtem to the follmO114. ,
Division of Water Resourics,Updergmund EnieLdon Coutrial Program,
6d Water levd.bdtm ground surface".' (ft.) 1636 StAil Sen'icc Center;Ralci„h;AC 27699-1636
Ge Outer rasing lcnr�,Nr{if lmllnn); {ft) 10c.Fnr Warer•Snnnh•isiniecttnu�Velos;" In addition to Sending the form to
the addresses) aboie. also submit one copy of this,form.withid 30 days of
comptction of tir-cll abandoirment ro the oounty health depailnienf of the county
6E Inner caxinjjtuhing,t6i:1th(iflmuct•n):
when itn,adoncd.
6g Screen Icugth(if known): 00
Fame M11-30 North Caro6tn Depadinem ofEnvirountcat and Narumt Resomces—Divisionof Water Rem" Revisal Au 1st 2013
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