Mecklenburg_Well Abandonment_20241014 (3)

WELL ABANDONMENT RECORD 110lWaulUsdONLY;
This farm can be used for single or muhipte%}ells
1,Well Contractor information: WELL ABANDONMENT DETA1 4
Robert Miller 7a.Number of%veils being;abandoned: 1
4YeIt'CodranorNstrrc,arsirttoVi rsoriall ilfanAardsi-uLtl,anhisiltrrproperty), For nndgple. vvj ruar or rwra-11W& uplxh, wefts ONLY will) tbe.-come
( Pc �' o cmastrrrctiiui,inbmrchHlNhgar,itincwrnjbaiUl'arefomi,
2675-A �.
7b.Apprnzlmatc rvdwtnc of%'sates-ntt►:tining;in nell(s}:_ (gut.}
NC Wd1 CnnliadorCanlfru-�Hon Niniibcr l; � -
sASDAcco FOR WATERSUPPi Y WELLS ONLY:
1;
Convarry Name 7e.Type'of dhiinfectant uird,
2.%Vc11 ConstructEon Permit#:70001218,
L8t ra11 Wp&vble urllyu arritr(i.e.Cuuuv,Stn'e,Yariamv.frleragm.elcl fumwri ?d.,lirionne of d1slnFectant trsal' I
3.Well use(ehedi.n•ell"sags:
Water.Suppiy Wetl: 7e.Scaling matcristls uscdCclic'ek ll that apply):
OAg tictdtilntt pMttnicipalipublic N Ncat Ccmcnt.Gwut Ea Hcatonitc Chips orN.Ilcts.
❑Gcotlicmtal(Hcatinocoolina Sripply) E IRcsidontial Water.Sirppiy(single) ❑Satxl.Ceulcnt Grnut ❑Dry Clay
❑hutustrial/Corruncaial ❑iicsideutUd 1Vatcr Supply(shared) ❑,Conetnle Grout, ❑Drill Cuttings
❑w •tion ❑Sp'titalty Grout ❑Grtvel
Non-Water Supph'1Ycll: .17 Bentouite Slurry 1; El Other(explain under 791
i9Mauitoritrg- ❑Rey o%en'
Injeetion Will: 7f.Iror`eaeh tti;dtcrEal selected abaEc,V ror�dc amount of.urtitcrials used:
❑Aquifcrlteclratgo ❑GtoundgnlerRentedialion Neat Cem.:941b. ,Wtr:7gal. Sand Cem.:lb ,Wtr:gal.
❑Aqud.!rSionlg a arxl ltecoveq ljSa%hy Dard.cr
❑Aguifer.Tesi ❑Stonm%atrr Dnthiagc
OEsperinrerual Technology dSubsidence Control 7g.Pro%ide a brief'descriptian of the au�batid anmcut proccylure:
❑Geotherinal(Closcd,Loop) ❑Tracer j!
Tremie.grouted with portland ,cement from the bottom-to
EXcothennal(H61inigMdolin Return) ❑0ther(es lain under7g) .
ground surface. �^ _
A k ;C' +N•i, ,i
4•Date n'dl(s).pbandoncd 9/23/24:
sa.Well location: 0 r 1 < 2024
Pine Island Country Club
T:acility/Ga-mrName FacihyIDNorapplicablc)
•1701 Stoneyridge Dr. Charlotte-, NC 28214 ,/� 9/30/2024
Plr}'sicalAddres:CilY:aridZip D;rto
Mecklenburg 03139101 fly aigning This fna?ri; i hereby certify dwr the ireil(s) eras(trene)abandoned in
Cnuuq' Parcel Idaffbi.idnu No.(PINT acxvnIance milh 1.5.4 AU lC 02C.0100.ur 2C.02601i elfCoiis'diucliun Rdackras
grid llrirt a cop}•of lliis record leas been provided to lfre well or nee.
5b.,I atiutde and lbnotade in degmeslminutestwconds ordecimal degree:;:
(tr c•ell raid,01b:1;106ng tc s41lTiciol l) 4.Site diagram or additional well derafls:
'You tuai use'the ba&of this page to p6 ide-additional.nti ll site details or%yell
N �V abaudolufleta details._You inky'also attach iuiditional pages if necessatyr_
c6NMItcri N DETAIL 5 OF WCU61 REIN%:ARANDONtiD SURN1171TAL 1"NSTRLTCfiONS
:fitudl tie11 Lofulmelldrr racurel(s) 'av�ulI&L 'Cru mnlopfe i)yec wa ur rwn•nxurr.hppfp
u>lla 01VLY JJ vdtfi tha svmetruranratuoirahoruknrin tit, uu rnra submit curelurnr 10;r. For All Wells: Submit this Forth %tiitltln 30 day5 of ctltnplction-aE%%ell
Ga Well IDfS• -2]R abandoamcat to the following:
DhIimiou of WaterResourcm,Information ProccsAng;Unit,
18.2 LG17 Dbuil Saitiicc Center.,Rulcigfi,11C 27699-16L7
Gb.Total well depth:
lOb.FPr Th leclion Wills: _In addition to settling Il>r foray to the addtess In l0a
abo%tl,also submit and Cap%•of this form itiirhin 30 days of completion of melt
Gc.Borehole diameter:2 (in.) abitndormrcut to the Follon'lirs:
II ,
Division uF Water Resout c Ni Uu6siround Lijectlou Control Prdgram,
lid.Water level below gtrtund surface: (ft.) 1636 Blail Smiec Center4'1 a41 .gh,KC 27699-1636
�I
Gc,Outer c sin Ica (if imo%rn); ( .) t0c,Fnr Water,Strriniv&iidgetton%�eDc: in addition to sending the form to
h �( the addresses)above. also submit and copy of this fomt within 30 days of
comptdtiou of well abandonment to theiooiIoU., he6llfi departnred of the county
G finer eaAnWinhing teng th(if knu%vn): (t:)
where alnndoncd,
f.b
6g.Screen length(If ktiowu): A)
Fomt GW--30 Noah Carotfin ikgnnarcnt of Eniimunrerd and Natuml Resources-61viston or WaterResearccs Revised August 2011
t

WELL ABANDONNIENT-RECORD Foi licmal UW ONLY: p 1
This farm caul be used ibr singtz or mul,lipte lye1is I 'I
1,Wcll Contractor Inf4rination: WELL ARANnONmPNT DFTAILS
Robert-Miller 7a.Nun ierofwellsbeingabandonell:1
\yC11C41lMCIC1af1\ante arweitoa'r� manall .dmaehittl>ioatiltunhisilicr ro 1t For rnulnple_ l+JerNae or raura-trtrte% Isirpidj, wells'. ONLY wtrb dw swne
I Y p p� Y1 �
' cwurtrrcltar�orrchtinn�Rat,)vnamsrittnN tsJFrrnr,
2675-A
\t 71a.Apprnzimxte vulumc of Crater rentaming in vvell(sj: ( d.)
14CdlConirwor olifiahiunN111RUT r
FOR WATER.SUPPLY W1 LLS ONLY:
SAEDACCO
Caa>ganytzartrc 7c Tyre of disinfectant used:
2.�Ve[I Caustructloar Permit td:70001218,.
Lid trAapplkvbleuegperinkr(i.a!Crnanh,State,t1trianrL5ltLbua:.elc)Y'hwjon 7de"nntofrllslnfectant used.'
3.Well use(0eck.n•eu use):
Water Supply Well: 70.Sealing materials used(cheek all that apply):
pAgticnittTtat ElMitnicipatl/Pttblic CM Ncai Ccincut Groat to Benton tc Chips or PNllcts.
00cothcmtn[(llcotinglC.aoliaio Supply) 012csidcntinl ty;•atcr Supply(single) 'Cl SaaO-Cc11 ertt Gmut ❑My Clay
❑lndusirial/Counit=ial 1712csidentW Water Supply:(stiatcd) 13.ConcwleGrout ❑DrillCttttin[;s
❑teal tioit 11 Speci tyGrow ❑Gravel
Nog-Water Stippl}'4Vcll; - -- _ 0 Bentouile Slurry 0 Oiher(explainundcr 7g1
Monitoring ❑Recoven-
Injection Well: 7f,.For each tuaterial selected above,provide antoutit df.titaitetials used:
L1Aquifc711ec[targm ❑GtpuiidwilcrRemedimion Neat Cem.:941b ,Wtr:7gal. Sand Cem.:lb ,Wtr:gal.
❑Agn[ferSronagc aixl Recovery OS:tlinity Ranier
❑Aquifer Test ❑Stomneater Dniiriage
❑Egteriutentel Tivehuo[ogv ❑Subsidence Control. 7g,Provide a lirief dcscrtptian of the Abandonment ptncerlurt:
OGeolbennal(ClosedLoop) OTracer
Tremie grouted with portland cement from the bottom to
❑GeothemT at(He:iGnatCoalinRRetum} NOthert� laiautader7l+}
ground surface.
a.Dafcwcll(s).ahandoncel: 9/23/24
5a,Well location:
Pine Island Country Club
.8.Certillcalioh;
Facilit}v�rncrNuttu Fa.;ilitylDaaCrapplicablc) If,:;.,,�,;,i'�,: •,;f,�:_,k,t v`
1701 Stoneyridge Dr: Charlotte, NC 28214c=i-`a 9/30/2024
Pli}'skal Address;City,stied Zip $igttlh:':t r v';r':°s a' ::ti-;::::2L:.- x+'.' r .Date
Mecklenburg 03139101 By sigpitAg ills form;I hereby certify that dw well(s)was(ive?,e)abtuidoned in
Cauuty Patrel IOcsulrxaUnn No.(PIN) racwrilame ivitk 15.4 X01C 020.0100.vr 2C:0200[Fell 0misiniction Slonrkinis
and Aral a copj,of ills record I=heoi provided to Are well owner.
Sb,l.atlrudc and longitude in dcgreeshninutes/scconds or dMoial'degr'I:cs:
(irn•pl,r`itd,elle lattAraa is suiT3cncrti) 9.Site diagram or add[doual well detalLc:
1'ou um}'use like bacl:11 this,page to provide additional hell site details or vseIl
A' �Y Aintl uu,rtidetaiis..Yiu tua}'also atlacltixlaiitiotml pates if ttecc'`saty.
CONSTRIicr Q7Pi DFTAII S OF WELL(S)BEING ADANDONED %jTBNttTTAT,tNSTRUCTTO YS �
:lltrulr trell rorartrne7ieira rncvrrlfs)!J'atvllrzGk. Fw tmrlfiple iaJeerion'w•r�n•utirtir supply -
u-elFsONLY widi the sumocrarismarraarc'rabanhrrrincm4 ion roar ssrbmfa cure nte. 10a. For All Wells: Submit dais fomi tsithin 30 days of completion of Hell
it
Well ID#:AS-4 abandourtwO to tW r0110Wing:
DIvlskinofWaterWsource* InforinationTrocem4up,Unit,
1617 Atail. '
Sef%icc Center;Raleigh NC 27699-1617
6b.Tatatmel[depth: 22.7 0 ,r �
1011.For Inleellart Wells: In addition to sending due fount to the addtess to IOa
6c.€emitole diantetew 2 pn,) above.also"submit one copy of this fom iii aitlii 30 days of camptetion of well
abi ndonntertl to the rollotving.
Divis[on of Rrater Resources,Uudggrpund Injection ConlrvPPrdgraut,
fid.Water level below ground surface: (ft.) 1636 lliaril."icc Ccntci;Raleigh,NC 27649-1636
Ge fluter c sing h ngth(if laup nj; ( ) 10c Fnr Water Seemly&Tislarinn We11s: In addition to sending the tome to
the,address(es)abode. n14o submit one"copy of this fotru within 30 d;kvs of
completion of well abandownent to the county health depliantent of the courtly
6f.Innercasin;;ftubing tcuy,Kh(if known): (ft.) tivhcrc abandoncd,
6g,Screen length(If kaoty u):
Farm GRr-30 Nonh Carohtn Depattrncm crentiroameM i—W Natural Resoures-Dhvisian of WaterResources Revised A"2013
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