Mecklenburg_Well Abandonment_20241014 (13)

WELL ABANDONMENT RECORD For lutcm l Usd C NLY;
This form can be used for single or niuliiple))•ells I I
1,W01 Contractor Information: )YELL ARANDONh11:NT DETA1L4
Robert Miller .. 7a.Numberofttctlsbehtgalandaned: 1
1tic]tCo,ttador Nanie(or:rtil oar.,f p,sgnatly uh�m mdrie well on hkaI&progeny j Fcw rkulnple N fcetiae or mwmiv1fer I slrpp v wells ONLY . will) lix, .sane
earisfrtrce,ul irl)afdanracrat)tirr+riutsnhriUfa,fa n.
2675-A
?b.Apprni;irnatc►nlnoee of txat�rrmm ttuind in itell(s}i (gal.)
iVC'tYoltConlrtdor•Ccitfif=tioriNnm6cr p I
SAEDACCO FOR%Yi►TI RSUPPI y%IEL[S ONLY:
CongangName 7e.Type of tlisinfeekant used: it
2:)Yell Construction Peratlt#:70001218,
Ltd all api>ltrable will p¢rmiie(ie.Cwlnrv,Srl4,i iNatxe:li�ec&orr.ctnl Pf{mrrsn !tLL Aitinunt Of dlslnfcctant used:
3.Well usr(ChFck RA.use): I,
Water.supply well: 7c.Scaling Materials ascil CcliMi all tlraEall v):
pAgricaltttral l7Mtinicipal/Riblic• M Ncat Ccnicnt Grout f ❑Bcntonitc Chips orNllcls.
110c tllicim:ti(icalillP):'oolitig Supply) ❑Rcsidontint%vatcr Suppt-(single) E,Sand Crutent Gmut El My Clad
❑IndustriallCotnrrtcvCial ClRcW.ctitial Wntcr Suppl,.(stiun:d) ❑Coat rete GroutI' O Dri11 Callings
❑bri Lion ❑Specialty Grunt El Gmvel
Non-Water Supply Well: - - ®13entot»te Slurry j, ❑Other(explain under 7S)
19Mmiitoting.. 171ttxocety.
tajcctign Well. 7G For'cath niater6nl selected"abme;pgotfdc amoaut df.titutcsialsused;
❑Aquiferidccltarl*e ClGtgtuxinalerRentediaitims. Neat Cem.;941b ,Wtr:74al. Sand Cem.:lb ,Wtr:gal.
❑Agtt(far Stooge altd ttceot'tny OSalhdn Battier
OAgrdfer Test EIStonnwater Dnihaige
13 ntetual Terhuotoev OSubside»ce Cotttml
" 7*Prntide a brli f description of the abandonment procedure:
BGeoihennal(Closed Loop) . 07 incer
Tremie grouted with portland cement from the bottom.to
OGeothemtal(Heittinty'Coolin Retain) 00tlter(e» lain under 7g)
ground surface.
a.Date tscl[(s).abandoncd; 9/23/24
Sa.Well to"iron: I -
4
Pine Island Country Club
$.CettiRcaBoh:
FacilitpUivncr Nana Fa:ilhy IDa GFapplicablc)
1701,Stoneyridge Dr. Charlotte, NC 28214 9/30/2024
Physical Address;City,and Zip 5 -•. - �7e
to Ibly.� •.F';:E.,-:;,..St!�'<'`1:�s`'s�serer .D�
I
Mecklenburg 03139101 - Jay+si�ililg tkis f,'irml,I herr_by certify that the wel1(sl m-ax(toW )ahandoned rri
Cautity Pareet 16s1di6601L Na,(PINj irccvnlancx tvah'IJA:4CAC 02t;,0100 or 2C:0200 R'ell Cvnstiatcuon StanrkrrYls
arid drill a copa,offlris rtecord leas been prodded to ilia it ell oirtoer.
56.I.ntitude and longitude in degmscslmlm'teslseconds or ileciaulAcsrccs.
(lfvvell raid,o,k I ultong is atiillietet 1> 9,Site diagram or additionatwell&h.11s;
You mr}•use ilk back of this page to:jrinvide additional.ttelr site details or well
N . W .abatirloi otent details. You may also attach additional pages if necessary_
l"MTRUCrION DETAILS OI•W1 LLtS)BFINe.ABANDONED 4,URNtrrrAi,rNSTRUCTfONS
Auad f.11 11 minhwelicn mr.Drd(s)lf'alw1wr le. For brulnple l)tfecdodur taJn•uwhr supply
Ivell9ONLY u-11/1 the,sinne IsDYACi101['rLartdONl:IEIll.I+IU[nn tl11l1tw"r vte f nm 10a•For All Wells: Submit t1r15 fond within 30 dot's of campiction of trill
6a.Weil M#:MW-17
abandoamcht to-thc followikq;
I
Ditvisiun of WaterRnirurets.Information-Prom_sink Unit,-
I617 Dfail.Scitiicc Center,ltalciO,NC 27.699-1617
6b,To tat well depth: 15.1 (ft.}
Ph.Gar.16lectlon Wells:'hr addition to sending the form to the addiess iu,Wit
(ht,}
ubote,also subunit this bunit otie copy o£ foiait itithih 30 days of completion of well
6c.Borehole diameter,2
abiutdamneu!to the fa11u}t•irty. ,
6d.Water t¢tcl below ground surface: M. Di%islotlpf waterResoutres,Und�crground Injection Coultvl Prdgratu.
1636 llfail"icc Cenki Raleigh,NC 27699-1636
In
Gc Outer casing length(if Impnn}• (fL.) IQc car Water Surinh&intcrrinri l�l'ella; addition to•
tile,address(es)above. also submit one copy of this senditg lbe fomt to
foil }within 30 days of
completion of troll ahandoiunent to thc'eauntq Itea[th depanmerg of the county
6f.inner"shionfinig length(iflotatt•n): (tL)
tthcr> atxmdoncd,
ft Semen length(if ltnotin): (ft)
Farm G%V-30 Nonh Carotira Deporuncm of Environment atYl Nittuml Resouxes-Dlvislortof Water Resoutces Revised August 20t3
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NVELL ABANDONMENT RECORD For lttmulUseONLY;
This form can be used for single or multiple Atm
I.Wctt Contractor Information: 3YFLL ABANDt1N61FNT DE TAl"
Robert Miller 7a.Number ofi%ds'beingaltandotird: 1
Well todtadorNome oracllour� aonall altamlonitt�uvll.anitisllter r n For withipla 'fr�ruar .au run-»refer supply sells O,VLY Willi Nre srv»e
i Ik S o N� 51 c•.xufnrcfinn,4a'rmrchrirm��r>t�vncrur.nrdviUlatl_16�rvt,
2675—A
N6i Wc11 CbnlradorCcif iftpiirin Nnrnbcr 71t.Apprukhnatc�rdnmc of vtatu' l ind in ivell(.r): .. (Atli.)
SAEDACCO FOR WATER SUPPIXWELI,S t7A1�Y:
Gurvany Name y
7c Typc of tllsinfi�ctat.t used_: is
2.Well Construction Permit 9:70001218,
LP3t rrJl r1pt,lleuble uell perlrr(ls r7.a.Cuwnlr5 Stcta.1'aru„a e.'brfecfiarr alcJ f bmtrn
7J..tintonnt uCJLilnfectant ttsevl:
3.Nell usr(eliomell utc):
Water Supply Well: 7e.Sealing materials used(elicck all thief apple):
prtgricultunt phtttnicipllfiubtic. NgtCcmcnt,GiutJt , ®Bctttonitc Chips orPOIcts.
❑Cirttthcrnt d(ttcatinglCnolin©Supply) -EAP idential Watcrb'trpply(single) ❑Sand Cement Grout ❑-Dty Clay
❑WustrialtComtmtcial ❑YicsidentiaL-Watcr Supply.(shtitod) ❑C6upele Grout. 17 Drill Cuttings
❑Itti lion ❑Speeiahy'Giout ❑Gravel
Non Water Supply W.cll: ®Hentouite Sluny �; ❑Other(explain under 7g)
19Matdtorine ❑Recovery !;
tajcction Well- 7f,For each ttiatetiid selected above,nrocidc amottrit-of•materials used:
I]Agrdler[tgcit q;e ❑GtouiaiuuerRentedialiau Neat Cem.:941b ,Wtr:7gal.. i; Sand Cem.:lb ,Wtr:gal.
13Aquifer.Sfomge and Recot'ely I]Salituty Barrier
❑Aquifer Test ❑Sloi.rncater.Dn.itiage �'
❑Eysetinteriutl Tcchnotogv ❑Subsidence Control. 7g,Pwside a hricf description of the altandonmcnt pnvccdum:
❑Geothenml(Closed Loop) ❑Tracer I'
Tremie.grouted,with portlanii cement from
the bottom to
OGeethcrtual(HeatiloCoolin Remm) ®Other( lainunder7Jt) .
ground surface. �I '
4.Datewell(s)abandoned: 9/23/24
5a �Yc18'lucation: OCT I
Pine Island Country Club
rkilityiOtvrat Namc Facility Ibs(Eapplkablc) S.CcrtiQcultoir. Ir`�.„.{:i rf�: ? ^ r,•;-s
1701,Stoneyridge.Dr. Charlotte, 14C.28214 y ,,� ( 9/30/2024
r/�'E � .s:J'�7'....
Physkal'Add>r�•City,and Zip Si lut.9. r•...t, a.•v;.'.kt! TSt=vti r D J1r
i•
Mecklenburg 03139101 I3y sigrting this form; I hereby certify,lhnt-the.rell(v)ryas p ept k abandoned in
(loeuiy" Pamel ltl:ntifikidrut No.WINj (IMMlmrce with I iA XCAC 02C.01004)r 2C.0200 Melt Gbnstiuctiun Stan(ktrrls
and&4i t a copy ofthis record has beeit provided to hire well owner.
5b,I.htitade and longitude in tlegrceslmlt.ru slsevends or dccitual degmcsc
(If ien ra kl,ow L111011.,is silrrwictx) 9.Site diagram or additional well details:
You uta}use the.back of this page to pi&ide additional cell site details or well
N W. .ab mdoinuent details.You may also altaeh t Mfiot.a(pagers if necessary.
C(DNSTRItcria-i DETAILS bH w LL(Sl BI:INR ABANDONED smtrrrm,tNSTRUCTTON5
.-HAmh trail cams-Lmetlurr racunIN if atididile. -liar rrurinple hgecrian or n6n.mrttr svpph' -
uilds ONLY IN&114 sastq tmrsrrvtrwn%a5 itrclarr:rcru.i.,rr cart arG,nil are firm 10a,For All .Weller' Submit this fotsti within 30 day-,of totupletion of well
Ga.Well IDS:
Mw-18R abaridounwal to the following;
DltVision of WaterRcsourcer,,Information Processing Unit,
1617 56itService Cctiter,Raleirliq KC 27.6994617
Gh:Tatal.t••cll depth: 36.22 (R.) i- .
10b.Dr Tn lecllon Weals: In addition to sending like form to.the addt%i in 10e
Gc.Flarcholc dlanteter:2 Cn.} �4r•nCso'submit out:copy of this fofiit withiit 3Q days of'completion of well
abandomtteut to Elie following_
Dirislot of Water Resources;Unde ground Injection Contnul-Prtigram,
6d,Water level below ground nurfacec (ft.) 1636[%tail Senicc Ccnlcr Raleigh;NC 27699-1636
0utcrcrshrglcn h(iFltaottv): (ft) loc.Fnr3blewSntinls•d;TIN fcetfon Wells; 11 addition-'to sending the font to
Gc
the address(es)abgyq, also submit one copy of this finis within 30 days of
complctioo of well abandoiunent to the�county bsarift depuimtetd of(he Comity
Gf.Inner easin;/tuhinglength(if known): (ft.)
vvlt=abandoned,
6*Screen length.(if imolva):
Farm G%V-10 Nonh Cerotltn Depatuncm of Env iromttenl and Naluml Resources—Division of WaterResoafccs Revised August 20t3
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WELL ABANDONMENT RECORD ror Imarail Md ONLY:
Th[s faun can be used for single or ntullipte*11s
1.Wctl Contractor Information: WELL ADANDONMENT DRTAIV;
Robert Miller 7a.itunbernftr�llsbcfnl;alrundnncd: 1,
%%1gJlCor1mC1orNnnte(ofu'etlownerNaonall al+stulallirigwallonHslkrpropcny) For narlople. tryeralo+r or wort-u¢Ver supph• wells ONLY with 11m .sonie
• � Cb1UrrlfCn(Nl•$baltLlrAIlA�91f}Y/NCcursulvlUfWt funn:
2675-A
NE<Yclt ConiraaorCcrlitiG+limt Nntrbcr 7b.Apprntdrnatc�nlume of vvatu•ir lai inx in
sAEDAcco FOR WATER SUPPLY WELLS ONLY:
I Company Name ,
7e.Typi`iafdisinfectartt used:
2.Well CoustructEolr Permlt 11:70001218, ,
114all altlafkoble nrll p¢rmiLv ri.a C+.urrh,SIMt%Yaraarxe;liyrcriar�,etc:y Jimarvn 7d.Amount of tllilnfectant n5141:
3.Well use(chccl:well use):
Water.Supply Well: N.Seating materittlsaseti(chccR all ititat apply):
pAgticnititnt pMlinicipallPttblio M Neat CcmcM Grout ❑Bcmonite Chips orPcllets
❑Gcothmnat(Heltine C'ooliug Supply) ❑Rcsidetuial Water Supply(single) t]Sand Cetmm Grout ❑Dry Clay
❑Industriall6runtcicial ❑iWdeotial Water Supply-(skated) O,ConcreteGroul ❑DdllCuldngs
17hri ation ❑SpcktiallyGrout ; d Gravel
Ron-Water Supply Welt: d BentoniteSluny 0 Other(explain under 7g)
Q9Mmi{loring ORecoven-.
Injection Well. 7f.For each material selected above,provide amount of materials used:
❑Aquifgrltcc[targe t]Gr6und%vderRented lion Neat Cem.:941b ,Wtr:7gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Stonige=1 Recovcty OSaliniti'harrier
❑ iluiferTe-A UStoirnw.rerDrainage
EtV. erintetual Techuologe• OSubsitlettct Cotaml, 7g.Provide a brief description of the abandnnrtient procedunn
Meothernial(Closed Loopy OTracer
Tremie grouted with portland cement from the bottom to
17Geotherntal(Healin tCoolin.$Return) ®Olher(e. laiuuoder7x)
ground surface. -I;-�.• _
d,pate well(s)abandonctt: 9/23/24 j•..•h b, ,: ft s' 'r'e{�„,R-.,
Sa.Weil localton: OCT 1 2024
Pine Island Country Club
r¢cilityaYlnnerNurrc Facility tVM(Tapplkable) 8.CertiRcaliou..
1701 Stoneyridge Dr. Charlotte, NC 28214 9/30/2024
Physical Address,City.audZip Sigrctlu� of%•+ F :' ;�:;.::::�t 'v,ti�+:vr>r Dye
Mecklenburg 03139101 Hy signing 11iis form, I hereby certify that,ilm well fs)was prere)abandoned br
Cauuty Parcel!rL rilittciUau Na.(PIN) actwid rue with Ii:1 hCdC 02C,O100.br 2C.0200 rPell t nrislirtcfiun Stnnr&inls
' euirl tlrrrl a mp��of{iris r'ecurd Jxts brew prrn>icfctd to 7Jre t+•ell owner.
Sb.Latitude and longitude in d4�a cesJm[natesfseconds a r dccinuafdcgrcese
(if%v0I rnLld,ola lad611g t%marriclA). 9.Site diagram or additional well deraiLm
You tua}•.rue the ba&-of this.Page to p�avide additional well site details or well
•abaudonmeut'detatls-You may also attaclttidditionalpage's if ne-essary.
CON'STRliyr 1/N D1rTAIL 5 OF WrI,IJ'.a BEING ABANDONED SURN1171-rAt.INSTRUCTIONS
:tltvtlt air!!rorirrrtri7imt r>+evnr(sl IjairotlaGln, lvu•tnrlaplr in�rfiwe'w•rxtn•uxrfin'supply
wells ONLYwthrtaesvmgcaurtrnrfuitr'aRoruhuriarcKtt.irarrcanslrlmitcnrdjbnrc 10a.'Far All Wells: Submit Ihis fam) within 30 days of completion of well
Ga Well m3: '19R abandonment to the following:
DIYbion of WatcrResltnreei.Infoivmtion PkaWssing Unit,
6b.Torat well depth: 16.75 (�.) 1617 Dfa[I Scioce Center;;Raleigh,KC 2 7 699-16 1 7
lob.ear In Iectlnn Weals; Lt addition to sending the foam to the adthesi to l0a
6c,Bart Bole d(atttetcr:2 (in,y :abom also submit one Copy of this focin�vithiu 30 days of completion of well
:tbi ndrinnlent to lite falln}ting: '
Gd,Water level below" bond st+rfacc (ftJ Division of Water Resouri s,Underground 6rjecdou Control Prdgratn,
p. i636 Mail Service Center,Italc[gh,MC 27697-1636
I'
Gc.Outer casing Icnptlr{if known): (fL) 10c Fnr Water 3urinh aCr-inler•t[nn Wells: In addition to sending the form to
the address(es) above, also su0nii1 one;copy of this four within 30'days of
completion of well abandtnnnent to the courtly heattia depaitnient of the counay
6L Inner casinWhibing tength(if lataw•o): (D) wltcrc olnndoncd,
6z Scre en length(if known): A)
Fomt MI-50 Nonh Carolina Depattnkm afEnvirounicnt and Natural Rmores-Division of Watcr Rcsoan ms Mlscd August 3013
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