Mecklenburg_Well Abandonment_20241014 (5)

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WELL ABANDONMENT RECORD For Irdmal Uso ONLY:
This form can be used for single oe nittltiple Wells i
1.W01 Contractor lnfonna_tion: WELL ARANNoRMENT DETAILS
Robert Miller 1Li'JunrberofAvettsUeinRabandonld: 1
%YCItCaotractotNamc(or%ttiU.bw 7 t%euonhisll:erpiaperry) For tnglapk Nfecumr or root-utlfr suplrh• aelb O,VLY 'wlrli r1,w -wale
rxurnrcncN,htSa+NhPlumer,r,IY,N C[DP SJlNIeI 1. 1ing
rml.
2675—A 3b.Appmximatc volume of water tei in irell(s): („ I
NeWcucomraaorctnitGldotiN,nid,ct
SASDACCO FOR WATFR.SUPPLY�vFLLSON Y:
ConVany Name 7c.Type of disinfictant used:
2.Well Ccusttuction Penn it t1:70001218, 1
Ltr,r1 nl,plkvbte kr'tlpumitY(.�!Corlett,Stun,l'ariam .Lrfereiarr,elcl If Giuwn
- 7d.t4utounCuf illslnfceE,int used:
3.Well use(ehcck well uu):
Water Supply Well: 7o.Scaling materials used(check all that apply):
❑Agrirnttitnt pMtrnicipyllPtr[�{ic W Ncat Ccmcnt.Gonut i I7 Bcmonitc Chips or Pellets.
AGeo helarnal("CminglC.00litig Supply) MIlesidcntial Water Supply(single) ❑Sam Centelu Grout ❑Dry CL•ry
❑htdrislrial7Comntcrcial ❑Residential Witter Supply(shaved) ❑Concrete Grout ❑Drill Cuttings
❑lfti •tiorr ❑Spegiahyy Grout i ❑Gravel
Non WatcrSupply Wcltl -- C1 Bentotdte Shim, ❑Other(explain under 7g)
❑manilotirre. ❑Recocety
injection Wctt: . 7f..For cacti ntateti;d setcctcd above,provide amount of.tuatedals ascd:
❑Aquiferltecharl;e ❑Gtottndwrterltenteitiatipn Neat Cem.:941b ,Wtr:7gal. Sand Cem.clb ,Wtr:gal.
17AquiferSrotugeatdlRccovery l7SaliniiyBarrier
❑AgnferTes! [7Stotun%yiterDraiiwgc .
❑Exp rintantal Tc huoloe_v ❑Subsidettca Control, 3fi Providc a brief description of the abandnumcnt procitilun:
❑Geolhennal(Closed Loop) ❑Tracei
Tremie.grouted with portland ,cement from the bottom to
❑Geethenml(lieafinalCoolipg Retum) P9Other(ex lain under 7R) . .
ground surface.
4.Date well(s).abandoncd: 9/23/24
Sit.Welt location,
Pine Island Country Club i
$.Cctllltcadoir, lli.`v: 'vn,i.'i,l� i�"!':r��k:_
Facilill�iQit•ncr Nlunc Facilit?•ID.I tifnppliwbic) t,
1701 Stoneyridge.Dr. Charlotte, NC 28214
Physical Addram.City.w d Zip vwr Date
Mecklenburg 03139101 17y sigr>lrrg thLs fatter, I heirhy cerdA,--11:ad tree irell(sj tress(irere)ahaudoned in
Cauuty Av.rel Id:,wifie:itlnu No.(PIN) nezvnIfence ivith 15.4 XCAC 02C,01OO.ur 2C.0200 11"vil Cvnialrrtetion Standeinis
and drat acop,rofilds record hay been pr�rld&to7Gett•ell owner.
5b,l,itittideand longitude in degmestminutcsfscconds'ordecinutl degrees:
(if,iCll�d kl,aw I,Ulnng isa,dliricq) 9.Site diagram or additional well dotal1j:
You tua}use ilk bacl:of U6 page to provide additional well site details or%cell
N W. abaudoimteut details. Yau run}also utaab additionaC pages if atecessaty.
e_ONSTRU rIM DvTAILs of WELtA)uriNC ABAND6NED SURntRTAl,tNMUCTFONS i
Atfudi%tell comirucHaa n-mreUs!Jf aiviWla. Far mnlnple OtkdiuN'ur rrjn•,rutar sylph•
wells ONLY n•uh simie rrrx(to,Nrrho relNur:,muwPN mn nihnrit wreJarm Ift For All Wells:' Submit Ibis fanny within 30 days of eompletion of well
6a.Weil IDS:
SVE-1 abindonmctrt to the rolloiving; i
Dtpisinn of Water Resource,Infot•tmition Procusink Unit,
1617 11Lii1 Service Center,Raleigh,XC 2769971617
6b.Total well depth: 8 At
10h.ForTitleclion Wells; tit addition to!kIndigg theform to the address in l0a
fie.Borehole dlaructet 2 (iu.) above+uiso submit Otte topy�of this fomi%%ithin 30 days of completion of%v�ell
abimdontnertl to-the follGwfiig":
i
Gd.Water level below ground surface (ft.) Division of Water R6ouncs,Uudei�t nd Lijectiun Conitvi Program,
163E Mail Scr icc Center,Ralcigh,XC 27699-1636
Ga Outer casing lenh(if known). roc For Watet•Sunnh•fi infection Wells: In addition to sending the form to
the,address(es) above.'atso submit bee coop of this tbuiy within 30 days.of
cornplction-of well ahandoiunent to the County health depaenient of the county
6f.InnereastnWtubing length(if known).- vv'lurc af>tndoncd,-
I
6g.Screen length(if liuow u):
Fana GW-30 North Carotin Dep3amem ofEnvirommill and Naumt Resomecs—Dlvision of Water Resolimcs Revised August 20t3