Mecklenburg_Well Abandonment_20241014 (4)

WELL ABANDONMENT RECORD rot Imerrial Usd ONLY; f 'I
This•fohn can be used for single or muliiple jitlls I I
I,Well Contractor Information: tt'1r LL ATIANDONMLNT-DETAEL.4
Robert Miller 7a.Nambcr 4Unkils bring abandoned.- ,1
wclfCaulw9f Name(of wEltoimgsRrsonallyAmnlonhiowollanhisthcrpripefly) For wufopk fiyeelloir or rmiminrei jsiipph• wells"•ONLY 'wilb Me .sme
(YN1SrlNCdr(N1 uV07rd(NINtJ*71r,lYIN ems."Nuir 1jerm.
2675-A
NC'\Yell ConUddorCcnlfualiori Nntn6cr 71r.Apptnzlmatc trtiwae of sFattK"�rillainin�in�)•cil(s}; (;pl.)
SAEDACCO FOR%ATER SUPPLY ATUS OidLY:
CouganpNama 7cTyp¢'ofdWnfectantnsed: !{
2.Well Coustlenction Permit q:70001218, , �I
Ltd 41 applhwble well1wirus!Lt C„ann;.Stut�•1'ari(ume blecrirtJr•.atr`.}rJ!ltuown .
7d:s"ant of disini'Mant'used:
3.Wdl use(eNeeliwell uu):
Water.Supph Well: 7c.So:dtnfi materials itscd(cb`cei;all that apply).
QAgrictdtur<oE ❑Mttnicipallrublic M Ncai&Mcnt Grout ❑D3 ntooitc Chips or Mlcts"
❑Gcoilicraud.(HcatingIC:ooliuo Srippty) ❑[tcsidctainl Water Sttppi}(single) t7 Sand Content Gmtit ❑Dry Clay
❑64114rial/Couunc164 ❑Rcsidcathd Water Suppl,.(shatai) ❑Couciele'Grou'l ❑Drill Cultings
131ni tian ❑Spee6dty Grout I. ❑Gravel
Non-Water Supply.Well: ❑.Bentotute Slurry' ❑"Other(explain under 7g)
❑Maultorine " ❑Re oeery
fujcetian Well; 7f.For each ttiaterial selected above,provide amount df.utatcsiats nscd:
❑Aquifgr Red tar(,�e: ❑Griiuitdnuerltenteditilioy Neat Cem.:941b ,Wtr:7gal.. Sand Cem.:lb ,Wtr:gal.
OAquifer Ston►ge aid kmoro-eq, b7 11601,Barrier p
❑Agitifer Test ❑Stommuternrailm'
1313-VerintetnalTdeltuolog► ❑subsideuceCbwml
7g Prgiide a brief description of,the abandonment pnotttilutt:
❑Geothemtal(Closed Loop) ❑Tracer
Tremie grouted with portland ,ceraent from the bottom to
❑Geothemtal(He<tGn�'CootinttRettrrn). 990therwx lainunder7 ),
ground surface. [. ;-`��;� •- ,_
4.DatCwcll(s).abandoned: 9/23/24
a.%Veil,location: l 1 l .2024
Pine Island Country Club Inf;,;
S.CetliRcaliail:
Fscilit)�tOn�rtcr Nmmc Fa.ilit}•Ibp Cl'appliwblc)
L�'r'u Lc•3f der
1701-Stoneyridge Dr. Charlotte, NC-28214 �; 9/30/2024 "
Physical'Address.City.and Zip Sic�cylt.� � ry.^r•'%+:'F;�!L""s;;'lc..�'i` •c to cur Uatc
Mecklenburg 03139101 13y.(ipzhq this form, I hereby certify that the tre11(.$)bras p ere)abandoned.in
Clouutl Pane_l Idadirkitinu No.(PlmV acconhaire tvtlh I U 4•L'rIC 02C.010b.i-r 2C.0260 Well"Coi'isdrttedion Staarkirtls
and drid a cnpv of dzis record has bebi,provided to dre well owner.
5b,Latitude and longitude in degme-Orninutes/seconds-or decitrtAdegt•ecs:
(ifnell fuW,orw Lirih»tg aatrrcieif) 9.Site diagram or additional well detall_c:
You witty use the back of this page'ta provide additional troll site details.or moll
N W ttbaudoiauznt details..You may also 2it0Ck additiontl pogzs if 11eceM1_V.
CONS'TRUC•HON DETAIL C OF lVELIAS)HKING ADANDOA1ED %URNttrrAt.INSTRUCTIONS
:ltlrJar ve!!evristrttellort nevnitsl rj'dvollrJik Feu mulliple btjecrton'Nr riun•nxrlcr.stJfxJly - i.
wells ONLY',Iddl[Ina snmrrvn+rrracrroh4r9ntrdrncrr nJt,iva mn,•nrbmt!weehnia 10a,Far 111•Wells: $ubtntt t1tRs fnmt"within 30 days of dotripletian of null
abtindoanwitt to tho following;I'
Dtgision of Water Rtsources Info-mation Processing Unit,
14.1 1617 Mail S&%Oec Ccntcr;,Ruleigh,NC.27699-1617
66.Total well depth: (D.)
10b.For lit Iecllan WclIs: ht addition to sending the fon►►io the addresi in IN
abovc.tilso•submit one tope of this form withttr 30 days of eomptetion of well
fie.Borehole diameter.2 (im) abitndotnttem to cite following: ,
' I
Dir,•islon of Water itcsouri s;Unde6. round In jecdon Control Program,
6d.Water levcl.bclow•givrund surface: (ft.) 1636 Mail Senice Ccntcr,1I,R iiciriy NC 27699-1636
loc.Far•Walgr 310 111V:&Ettleetlan it In addition to sending the font to
6c.Outer casing length(if lmqw"n): 00 tile"addresses) above. also submit one icopy of this fortis within 30 days of
comptetioti.of%"tqi abandgnmeut to the coonty health deputuncid of the county
6f.Innereasing/tubing length(if ltnuwn): (fp) syhcrc atrtrulotictl,
6�Screen length(if U011 n): (t.)
Form GRr-10 Nonh Carolina Department of Pnvirountcnt and Narutst Resources-Division of Water Resonices Revised August 2013
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