Mecklenburg_Well Abandonment_20241014 (12)

N ELL ABANDONMENT RECORD For IMctn d Vw ONLY:
This foitn can be used f6r sirtgte or.niuliipie iVells
11 Well Contractor Information: WELL ABANDONMENT DETAIL,%
Robert Miller 7a.N mberofivdisbeingaltandanel: ll
WellCouimbe f Name(or wAl.6%t wtsp oiullynliunlgrilveuetl.onhistirrrpiapcn}). few rwrR,ple.. ftyerNwt or _fwn-welter SrtpiJ MaI1S" ONLY uab me sonic.
• caustrrrcttovi.m5ardwtuier,t,}vn ciur s;aEvnlf a', ran,
2675-AI•
7b.Appmrimate►alums of tratci tvvnainm8 in vti_cll(r}: ( aL)
N6'N'ctt CnnladorCpnlficatiau Nntibcr �� 1' -
SAEDACCO FOR FF'ATFR.SUPPLYFYE[[S f?NI:Y:
i
Conq+anyN'ame 7e TiTit of disinfectant used.-
1 Well Constrtiction Permit 9-70001218
Lw till upjVhwbi JTjjfarirr;iv(;.a CunrlhSt,1c.t'orlarn�:I,;erhaio..r1C}Pftm�wM 7d.rFtttonnCafdisinfcctslnt"uSel
3:Well use(sheds vv ell
Water Supply Well: 7u Sealing Materials usett(clicei:alt d1 lat apply): .
-1JAgricultunL 17MiiniapaVPublic l8 Neat CcnicoGGmut 13 lkotouitc Chips orI dlcts
17Cirnthcrmnl(HcatignlCaoliuo S»prl}) I]Itcsidemittl Water Stipp$(singlcj ❑Sand Cetni nt Gmut ❑Dry Clay .
❑tlndnsiriallCornntcrcial 0110ident[al Water Supply-(stt:•ircd) O Concrete Grouc C]Drill Cuuin s
❑hri •tion ❑skoalt}Groat ❑Gravel
Non-Water Soppta Well: El Bentouite 51urw Ct Other(esplaiaunder 7g)
ImMoiihoting - ❑Rec:ovety
Injection Well: _ - 7f,.Flor each nAaterlalselected'aboye,pi�othde.imout.it.6f:tttatei•iatsttsed:
❑Agnifrrltec[rarge ❑Grquiidty ueildentediiUioti Neat Cem.:941b ,Wtr:7gal. Sand Cem.:lb",Wtr:gal.
13Muifer Storage attd Reioveq 179athiity Barrier
❑Aquifer-Test ❑StomnvvterDrtitiag� .
OExperintertlal Technology OSubsidence.Conttul 7g provide a brief description of the aliandnnmcnt prrrcttiltrec:
06cothennal(Ctorcd Loop) ElTtacer.
Tremie grouted with.portland ,cement from the bottom.to
i.C3Geotlwnual(Rea(ingICooHngRcium) ©Odwi-(ixA- lain under 7 ) . . - . - .
ground surface.
d.Datewell(s).abandoned: 9/23/24 "" `;� ..•. �,
S&L FVell location-
Pine-Island Country Club
Facilit}"iQvvncrNtunc Facilit}1Ds Cfappliwblc) 8.Cerlification:
1701 Stoneyridge Dr. Charlotte, NC 28214
9/30/2024
Physicai'Address,City;aielZip Sietclh"t.e"jwr+i :ems::;;t !tt d.vrt, oats
Mecklenburg 03139101 By slguhig This for,n: I hereby certify'that the irell(s) Eras(weir)ahandmied#t
Cmiuy Pateel ldemlfbe ii ait No.(Pl!Nj auwnloncc i pill?'1 i-1 tiCilC 02C,0100,br 2C.0200 rMell C6,virnction"shinrkinls
andthatacopyofihisrecord liar be:eiipi-oldkdto"lire welloltner.
Sb..I ltihtdc'and longi#utte in;d�esrinlatut�cstscennds ordccinttrfdcgr•s�a
(If ti•ell raitti,orut Wton;is avlfirtivil) 9.Site diagran1 or additional well details:
"You tuap"useihe ba'&of Ihis.pdge to.pibvide additionat wall site details or uA
)1 W, abaudoitnieia details. Ybu tuay alsp atlath additiaualpoges if ttec�,sat}..
C0N4TRltC"rI0ti1 DFTAIILS OF tVELL(Rl BEING:ABANDONED SUBM1I 77TAr.IN9,TRLCTI0N5
:luotb n_e11 cv�ixviructian ritnreits)'!j'availnrila'. Fiv,rer,lhplr iitlerriar:'ar grain-ttxrtrr arrp/,17' i
u i1b UNLY'v,lti,ilia svm�rwrsrxerteme'arinrrcw,:i.,rnr iou exm a�Ggnt ere junco 19a.For All-"Wells•- Submit this to %vittvn 30 days of completion of ur11
6a.Well ID0.14w-13R abtindonmeut to the fallovtiiag:
Dliision of WutcrRecaurc�i,lnfoitwtion Prucesiin�O1nit,
66.Total.vtcll depih: 1617 shill_"ice t"cntcr;Ralcigh,NC 27.699-1617
.
10b.I+or- lecilari Wells; In oddiiibu to sending the fonu to the addiDss to 16a
6c.Borehole diatuctet 2 {itt,} above,also submit one cops of this form asidtiu 30 days of coruptetion of well
abaniiomncnt lei the following:
Division of Water Reson rres,I)pdetxtnuud hijection Chu(M Pr6gram,
fill.FVatcr[etd bclors 6rynutid sttrfuse; (ft.) 1636[%fail"ice Ccntcr,Italci;gh;NC 2 769 9-1 63 6
I,
10c,Fn r\Voter Su rink iF.Tie icctioro F�'ells; in addiEion to sendikA the fomi to
Gc.fluter casing length(ifImonn): (D) the Mdress(es) abo%'also submit on3'copy of lids fatrtt)vitltin 3.0 days of
complctioti_of will ebandowneut to thr county health deparnitent of the county
6E Inner casin�� nbin g ten tth if lamwn• vtltcrc abandoned.
.,/t 3. 1, (• ). (tit.)
6g,Screcu length(if known); 00
Farnr GR'-30. North Carolim Depanmem of Environment and Natural ResowT s—Divideii of WaterRooams Revised Atka!!2013
11 '

i
NVELL'ABAND-QNMEN.T RECORD For ImcrndUmONLY:
This'form can be used fbr single or raidtipte malls
1.WcH.Contractur lnfonuation. )YELL ARANDON4IFNT 11FTAK
Robert Miller 7a.Number df trells berm!abaudoneds 1
�l�clfCorlmcforNsuh-(of tttlloivwpeagnallyamn"Withaou6Hhisillerpropcny) ,For tagla le fJfevllaf or non-rirafol•�supph•. Kaf&- ONLY with Irk.-some
rafurrtrctiai•i mt<kuJrrt�elt inn cwf.sr+hwUYateIforwr.
2675-A i..I
7b.Apptnslmatc►nluinc of vi ate rcrn rrning in iv dl(a) ( of)
NC\Vcq ConlJaaorCritlficnNoii Nmi3tef
SAEDACCo FOR WATER SUPPLY WR[LLS ONLY:
i!
ConqunyNama 7cTypeufdisinfietantused: �-
2.)Veil Construction permit(};70001218, ,
Lwatt vp1,11,a le uetlpelnritr(i.at CvanD,, to,e&L ffkWwq 7d:elmonnt of diSinfCcfsiut"tlse4l'
3:`Vrll us><(chc¢Ica•cll navy; - - .
Waster Soppy Welt: ' 7e:Sca0 rtratcriials used(chccl:all thAt apply): .,
pAgricvlttlraF plNtinieipaJrPtrblkc' DO Ncat Ccmcnt.Grout. la Bcrdonitc Chips or Pellets,
QCfeothcnrull(Hc 0mi Cooling$ripply) �Licstdttrti,�l Water StJpply'(�inglc) ❑Sand•CentOld Grant i 17 Dry Clay
06JdustrialtComnrsrcia11 ORCSidentiat water Stipply-(shared) .O C©ncrcte Groua iI' C7 Drill Cuuinp
dlrrl tion CJ Speeialt}Grout I O Gravel
- ----
Nop-Watcr Supply Welh' O'Bentoaite5luny I l7 t7ther(caplainunder?$)
29Mmiitoring_ Oltecoivtry
Injcetian Welk. . .7f_For caeh Material selected-a-bGve,provide amount of noaterials rued:
OAtlniferRccharg6 Mr6undwiterRenwAWtion Neat Cem.:941b ,Wtr:7galL. i Sand Cem::lb ,Wtr:gal.
OAgnifer Stomge arxl Recover I]Salinhv Danicr
❑Aquifer.Tcst OSt6nmFvter Dnrivaye
OE.verintetualTechnology tiSubsideuci_Coniml, 7r,Provides hrt ticscrtpttongtthealrandnnmcntpryicidure:
I7Geatherinal(Closed Loop) . OTracer
Tretnid grouted with portlana cement from the bottom to
'Mothenual(Hei tip Coa Retum) ®Other(e.1 lain under 7 ) .
ground surface. �T _
d:DAicieell(s).abandoned, 9/23/24
- r•a_ . a
;a.Well location: 0 G1 1 [074
Pine Island Country Club
CeMllkation;
" Faalkt)•it7nncr NJtaJtc iScili�•Ibs(ifappli:able) .8. '�;� -^•we.;,. ,�t���.
1701 Stoneyridge Dr 9/30/2024..' Charlotte, NC 28214 yf �
;hysical Addr m.City:and Zip Si lr,�:a"j e,:• :t�::• �tt�' v*�4n't Lr .Dais
I
Mecklenburg 03139101 Jiy sigJting this farip,J lxmby certify•i'hrrr the tre11{s)was(rvert}abandoncfl in
Coa'6k Parcclldesitit7'cUML No.(t'INj ne�unfcuteeivtdh'dS.ltiC�tCD2C.alfi'J riC.(1_0[1tf'e1l.GmistructiunStrtnikirrls
mrd fiur a copy of tfris record htfs been provider!ta'tlra trelf olMer.
Sb.><.atihrde and longitude In ttcgrca 1h tutu9/smnds or dccimal°dcgr'eesr
(irti'oll ra W,otto 4'trflnag is W8ex19) 9.Site diagram or additional well details:
You map:rse.tliie ba&of this edge to provide.addirional.sell Site`datails:or w4ll
N W Akindoiunerudctails..You tua5'�lso;tiachudtlitionatpa�s if flea�an
CON9TRUC 1 ON.DF:TAIL•5 ON WELLf�S+i nLINf:ABAN16ONil) SURNMTAt,DVc,TRUCTFONS
Af adf tlCti[UfL,'trJlCrl7tf!fTGUJl�(5I iJ IIVYl11t3tIL 'i'Ltt lR111ttp1N lJYfeLtlf3R Ur'13771•uWJin sJlpplp
114&ONLY 11'ntl Ilk SVtlICCtiJ(SbEYtbfJJ['OJOttYhltllJlCNJf.1+ltt CU.0 kltilfr ,qte jbtt2 - i0a, lint All Wells:� Submit this fnmt ttithin 30 days of completion of it-ell
6Jt Wcl!IDg:Mw-14R It;andovrrw tt to tW fallowing: i!
DI'ision of WAtefResnureq,Information Processing Unit,
68.85 1617 Abil Service Center,Ralcij(h,KC,27699=1617
6b.Total siell depth: (It.)
ii
ibb:ToOrilmlign Wc•Ils: 1n addition to seoding the foral_io the address lu 103
abort,also suNnit,one copy oC this foipr:n'ithin 30 days of compterion of well
6c.Borehole diameter:2 (iu.} abindonutcul to the follstisiny:
l
Division of WntcrRcsoutres;Uudet'�rountl Injcctiou Conttirl lirtigranr,
frd,SVatcc Ic.cl.bc[on ground arrfaccF. (Fr.) 1636 NIA Service Center,Raleigh,RC 27699-1636
+
10c.Forw
6c.Outer-eosin rfImoSvo}: ( attr:Sutinhdtifriectinn�YellA: Lradditionto"serrdit�theformto
g Icn�( ) the addresses) above. also submit bne copy'of this-form within.30 days of
completion-of well aband_oWnrnt to the downy health deplidntent of the county
6E Inner enAnWhihinp teajgth(if known):
w]rcrc altandtancd.
6g.Streen length(if knoll a): (t1.)
Fornr GW-an Nonh Carotlm Dcpwomm orEnvironJncei and Natural Rcsomces-Division of Water Resources, Revised Atipa 2013
+i
t, .

WELL'ABAND-ONMEN.T RECORD For lmamalUscONLY:
This foim can be used for single or multiple%%efls
I,Welt Contractor Information: ) FLL ARANDONMENT DE TAILS
Robert Miiier 7a.Number ofirclis being abandoned• 1
K'CIt C.aumclorName(or welt owea p manally dl mialdne%,211 on ldsllier prepeny) For Irldnple. rryeoftor or rormitirey I s epfJr wells ONLY . wul; lice .sane
C6114f7tfCbCN1•$iJO1fc1UJINli7dr,lY1N canS711dNltr 10.'ICAZ
2675—A14C'1Pa11 G�nirJdorCClllfiGllffit!Nnlrbcr
76. I is„'cll(s): (old)
SAEDACCO FOR WATER SUPPLYWE:LLS ONLY:
Caalpatt}Name 7a Type of disinfectant used:
2:`Yell Construction Permit 0:70001218, ,
List[dll applhvlrl¢cell/4rmiLr(iaL CuanR,Srma,drurltLxe:liyrciPurl cic l Jt7trlWrd 7d.Amount aCtlislnfeetaint'usLA:
3.Well par(checkULU use):
Water Supply Well: 7e.Sealing mated s"used(chcck all that apply):
ElAgricultitrtl ❑Nlttnicip,•tlfPubtio W Nat Cement Gmut ❑Bctttonitc Chips orK-licts
❑Cleothenrcil(11caline,,JC401ino Supply) Qkcsidctt(ist Water Supply(single) ❑Sand Cert>ent Grout ❑Dry CL-ty
❑Indtistria]lCotitntc�Cial ❑Rcsideat4•tt Water Supply(sliarod) ❑concrete Grout ❑Drill Cuttings
❑brig tion ' ❑Speeialty Grout ❑Gravel
Non-Water 5uppt}•Well., 0 Hentotute Slurq ❑Other(e..\plainunder 7g)
mmouttorirle. ❑ltecovery
Injection Nvell: 7f.For each tuaterial selected"above,proside amount of materials.used:
❑Aquiferldecbarge ❑GmundnuerRemediatiou Neat Cem.:941b. ,Wtr:7gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage a1 d Recovery ❑Sourly Darrier
bAquifer Test ❑Slommuter Drairiaue '
❑Experinteulal Techuotog_y ❑Subsidence Central 7g.Pru idr a brief description of the abandrundent prncedun:
❑Geothennal(Closed Loop) ❑Tracer
Tremie grouted with portlana cement from the bottom.to
❑Geothermal(H6(i2 Coolie Return) ®O(hcrles lain under 7 )
ground surface.
d.Dated►ell(%)abandolred: 9/23/24 � �
5a.Weil location: OC Ir�1
Pine Island Country Club
Facilii?'dQnrrrNluec Faailiti1De(ifapplkablc) 8.Ccrlillrnlloir: ? ":-` 4; •.
1701 Stoneyridge.Dr. Charlotte, NC.28214 ..y� ��J 9/30/2024
Si71 ' 9?` •::::St. nt Lr Uau
P6�sical Address,Ciip.and Zip
Mecklenburg 03139101 By sigillydg this prinj I hereby certify rldar the a e11(c! wax(teem)abolldodled in
Cauug Rated ldaditwition No.(PIN) tdr:cvrrlan a will;I i-1 4CAC.02C.0100.irr 2C.0200 Mell Cvna'h7tc1iorl Sfarirkirt/s
and drraf a mpyrbflhis record I=been provided o dre ir•e1!owner.
5b,I:ttiurde aad lbngitude in degmeslndinrtes/seconds or d_ecirnal degrees.
(ifn•r:ll fiacid,ota:4'It/Ioitgte,gllrtieicldl) 9.Site diagram or addidonalwelt details:
You tuay use the bac);of fl6 page to pll wide additional well site details or%tell
I\ �Y •abaudoiuuettt detnlls..You ma}•also attach udditional pages if ttec:essaty,
CONSTR14TION DETAILS OF WE:LL00.BEING ARANDONED SURNi TTAL INSTRUCTIONS
rrruclr bell ctJrrrracfilirt racvnlfsl if'uvhllrbli. ror multiple ityedicor or ma-utrdar supply '
irllsONLY ulfll rim 51711MiGJOOYfCrfLINLUIrllulrl!IMIr,It V[Y1I731rGrirli Wref nm 19a.For All Well.% Submit this fotrit wiillin 30 days of completion of well
6a.Well 1Dfi:MW-3.SR abandoanicat to the fallowing;
Dtvisiau of WaterResuu=c ,lnfumution"Piucewiing Unit,
1617 Mail Center Raleigh, 27699-1617
6b.Total e'en depth: 27.75 (R,)
01j.ror.T6lecilon Wells: Ll addition to Sendigg Ilse form to the-aidtess to l0a
abode,also submit one eopp of ibis folio within 30 days of completion of welt
6c,Borehole diameter.2 (hr.) abandounwat to the
fallowing—Division of Water Resouries,Underground bijectlon Couttol Progratu,
b 163E Mail Ser icc Center,Raleigh,XC 27699-1636
Gc Outer casing Icn h(if[mown): ( ) toe.Rnr'Warer'Snnnls'",Cr iiriertiun Yells; In addition to sending Ibe foml to
the address(es) abode.'&o submit one copy of this fotnt %v!thin 30 days of
completion of well abandonment to the county heahh dcpanntern of the con no.,
6L Inner easin,t/tnbiap length(if lmown)e (D;) %vlurc atxtndoncd,
6g.Screen length(if known): A)
Fomr G%1-311 North Camtltu DepalutXru of'Fnti iroumcrlt and N uurat Resomracs—DIvisian of Wntcritcsouscs Rc%,Wd August 210 t3