Mecklenburg_Well Abandonment_20241022

q. . �j77� �T�may,ATT RECORD. I I
V�] LI1 ABANDONMENT 1 ForinternalUseONLY: I
' This form can be used for single or multiple wells '
i 1l,, c PP,3,1191-1 i
1.WeeIl,Cotdtracfto�rtInformation: • •WELL ABANDONMENT DETAILS -
fo'';' 2 • _ +,A,eI1/J1 7a.Number of wel •being abandoned: 1 •
Well Contra tor-Name(or well owner personally abandoning well on his/her property) For multiple infec on or non-water supply wells ONLY with the same
I construulon/abandonn6ent,you can submit one form. it
. 21P- 4 I •` 7b.Approximate volume of wateriremaining in well.(s): (gal.)
NC Wel/Contractor Certification Number
. i � // g t1 ill FOR WATER SIMPLY WELLS:ONLY: P
Company
N e • }✓yy ��y f �p 1 7c.Type of disinfectant used: I L "4
2.Wen Construction Permit#: {/f 1 /' // m i.94 .
.List all applicable well permits(i.e.County,State,Variance,Injection,etc.)if known D
7d.Amount of disinfectant.used:'
3.Well use(check well use):
Water Sup1 ly Well: 7e.Sealing materials used(check all that apply), •
0 Agricultural ❑Munc'pal/Public 0 Neat Cement Grout entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) l+ fire idential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
•
❑Industrial/Commercial I ❑Residential Water Supply(shared) .0 Concrete Grout l 0 Drill Cuttings 1
❑Irrigation - ❑Specialty Grout . 0 Gravel
Non-Water Supply Well: . 0 BentoniteSluny 0 Other(explain und r 7g)
❑Monitoring ❑Recovery ;'
Injection Well: 7f.For each material selected above,provide amount of materi is used:
9 RechargeI
❑A vifer • . OGroundwater Remediation tXt5" x5o' j fi'}q.5
.... '
•
i.
❑Aquifer Sjorage and Recovery OSalinity Barrier •-
❑Aquifer est• • ❑StormwaterDrainage • -
I • .
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of`the abandonment procedure: •
❑Geother it (Closed Loop). '❑Tracer $
❑Geothermal(Ileating/Cooliing Return) ❑Other(explain under 7g) • I• • ti,. ham ', ,•_, a/f '.,.,
4.Date wells)abandoned: — r�. ! ••. .,. O C T '2 2 2024 •
5a.Well location: • r ln .: . ;a.'.rlr:.,; .a:yes.`: .
• . • '5) r& bot70(45 XTliPin ilellih ': . . I D'itiii-.6 1';r',":". 'A ". • '
S.Certification: J� ... l t�
Facility/OwrerN a Facility IDii(if applicable) i �! �`
i 6).•15A1 I 51.1K0.;31//1167 1V (7)-high P5 4,,,
Physical.Address,City,an Zip Signature of l)rtified Weil.Contractor o'r Well Owner • Date '
r/ �! { By signing this form, I hereby cent fy that the well(s)was(were) abandoned in
County 1 . Parcel Identification No.(PIN) accordance with 15A'NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has bee,?'provided to the well owner.
• 56.Latitudq and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,dine lat/long is sufficient) 9.Site diagram or additional well,details:
�.�s ,1 X el N it 7 /r (' ,�i You may use the black of this page to provide additional well sit details or well
ht ry W abandonment'details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUB1VITI FAL INSTRUCTIONS I .
Attach well construction record(s)if available. For multiple injection or non-water supply I i
wells ONLY with the.same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of confpletion of well
6a.Well ID#:
1 I abandonment to the following: I '
Division of Water Resources,Information Processing Unit,
1617 Mail•Service Center;Raleigh;NC'27699-1617
•6b.Total well depth: . tl (ft) .
it 10b.For Injection Wells: In addition to sending the form to the address in 10a
• above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to'th following:
s Division of•WI ter Resources,Underground Injection Control Program,
6d.Water level below ground surface:a (ft.) 16361Mail Service Center,Raleigh,NC 27699-1636
— 10c.For Water Snooty&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): •(ft.) the address(es)'above, also submit one copy of this form within 30 days of
t completion of well abandonment to the county health department of the county
6f.Inner i asing/tubing length(if known):_ • (ft.) where abandoned.
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6g.Screen length(if known): (ft.)
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Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resourees Revised August 2013
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WELL ABANDONMENT RECORD. • For Internal Use ONLY:
' This form can be used for single or multiple wells 1,1
• 1.Well
CCont ctor Informationnj: ,f r ) •WELL ABANDONMENT DETAILSI • -
7a.Number of wells)being abandonled:
Well Contractor Name(or well owne personall abandoning well on his/her property) For multiple injection or non-wafer supply wells ONLY a th the same
rT ) construction/abandonment,you con submit one form.
•
NC W 11 ContraeW�rCertifica[ion Number 7b.Approximate volume of water remaining in miffs): /17 (gal.)
. / e-/r 3j $ •_ t, FOR WATER SUPPLY WELLS ONLY: I•
Company Nan{e ' 7c.Type of disinfectant used: dill v t
2.Well Construction Permit#:
.List all eviler well permits(Le.Counq•,State,Variance,Injection,etc.)If known 7d.Amount of disinfectant.used: Z
3.Well use check well use): ,
Water Supply Well: 7e.Sealing material.;used(check all that apply
❑Agricultuilal G ❑M icipal/Public 0 Neat Cement Gros t entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 1 ORcsidential Water Supply(single) 0 Sand Cement Groat 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ' 0 Drill Cuttings
❑Irrigation 1 0 Specialty Grout .1 0 Gravel •
Non-Water'Supply Well: 0 Bentonite Slurry 0 Otller(explain under 7g)
❑Monitoring ❑Recovery I
Injection Well: • 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 3 ' 1' 24-F •
❑Aquifer StorageoI and Recovery ❑Salinity Barrier •• •
❑AquiferTdst- • ❑StormwaterDrainage - •
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: '
OGeothermal(Closed Loop). ❑Tracer a�-. y J r� I JeV—... .,.:� , `
.• ❑Geothermal(Heating/Cooling Return) ► •
❑Other(explain under 7g) ., / / , f ' �' ,. s „ i,- = F •
'1 6'
i.
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4.Date well(s)abandoned: / 2•� —A v/ U I LO`
Sa.Well location • it 1`G: <,:a:; r'::^.y.:a
Facilit/OivnerName Facility ID/I(if app icable) 8.Certification:
ail. •t 9- Al" 24
Physical lAdd,ll s,City,and Zip Signature of Certified Well Contractor or.Well Owner •• Date
�lye °i ) I •
f Jl / By signing this for ,I hereby certifr that the well(s)was(were) abandoned in
County Parcel identification No.(PIN) accordance with 15 'NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy oft record has bee•n provided to the well owner.
li
. 5b.'Latitude arid longitude in degrees/minutes/seconds.or decimal degrees: I
(if well field,one lat/long is sufficient) 1 9.Site diagram or additional well details:
3 , 14.7 f l r� e p4 7#63 You.may use the back of this page to provide additional well site details or well
✓ , i% i 1 (�`t C / /' W abandortment'details, You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED • SUBMITTAL TAL INSTRUCTIONS
Attach well 4onstruction record(s)if available. For multiple injection or non-water supply I, .
wells ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this-form within 30 days of completion of well
6a.Well MTh I abandonment to the following: j .
l� Division of Water.Resources,Information Processing Unit,
"� • 1617 Mail Service Center,Raleigh;NC•27699-1617
•66.Total well depth: (ft.) I
10b.For Infection Wells: In addition to sending the form to the address in 10a
• above,also submit one copy of this.form within 30 days of completion of well
6c.Borehole diameter: 3 (in.) abandonment to thelfollowing.
•
ft.) Division of•Water Resources;Underground Injection Con rol Program,
6d.Water level below ground surface: ( 1636 Mail Service Center,Raleigh,NC 27699-163
•6e.Outer casing length(if known): t (ft.) the
For Water Supply&Injection Wells; In addition to sen ,ng the form to
the address(es) above, also subrait'one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
.� where abandoned.
6f.Inner Ling/tubing length(if known):_• t (ft.) -
6g.Screenilength(if known): -` (It.)
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Form GW-3p J North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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WELL 24.13ANDONMEJ 1 RECORD •
For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS 11
JOHNIIIY HART JR I '
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wellsbaving the same
Well Cont a+Name(or well owner personally abandoning well on higher property) well consimction/depth,only 1 GW-30 is needed. Indicate TOTALNUMB)R of
wells abandoned; i
44
NC Well Coniracro Certrtificcaation Number 7b.Approximate volume of water remaining In well(,): (gel.)
ONLY:
FOR WATER SUPPL WELLS O :
MCCAI I BROfHFRS INC.
Company Nape 7c:Type of disinfectant sed; HTH , �.
I u
2.Well Construction Permit#: ` 10014890
List all applicable well construction permits(.e.rUIC,County,State,Variance etc.)tt(known ' +
7d.Anmunt of dlsinfectimt used: •
3.Well us4r(checkwell use):
Water Supply Well: 7e.Sealing materials used(cheek all that apply):
DAgticulttl#al ❑Municipal/Public 0 Neat Cement Grout •Bentonite Chips or Pellets
OGeothern!tat(Heating/Cooling SupplyResiclential Water Supply(single) 0 Sand Cement Grout . 0 Dry Clay
Olndustrial/Commemial ❑Residential Water Supply(shared) 0 Concrete Grout I El Drill Cuttings
DIaigation 0 Specialty Grout i 0 Gravel rj
Non-Water Supply Well: ' Cl Bentonite Shiny I 0 Other(explain under 7g)
❑.Monitoring ❑Recovery I'
Injection 111111: 7f For each material selected above,provide amount of materials used: •
OAquiferRct;harle ❑GroundwaterRemediation 120 BAGS II {.
❑Aquifer Storage and Recovery I O Salinity Barrier
❑Aquifer 3fest ©Stormwater•Drainage
❑)xperhnenial Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ti
❑Geothermal(Closed.Loop) OTracer
GGeothernial(Heating/CoolingReturn) I❑Other(explain under 7g) CHLORINATE WELL. SLOWLY POUR BENTONITE
INIU:'WtLLUNIILFULL.' !., . n ' i .1
fr
4.Date wets s)abandoned: 9/13/2024 • I' �+
, or'
9, 2024
5a.Well to tion . .
CRP—WiP MINT HILL. I a'"."--
Facility/Owner Name Facility 1Dtl(if applicable) 8.Certifiiation:
I.
12381IALBEMARLE RD CI IARLOTTE,NC 28227 I114 9/16/2424
Physical Attics,,City,and Zip Signature of Cortified•Well Cbntraetor or Well Owner Date
• M EC KLE N BU RG 111-201-07 I
By signhrg this'form,1 hereby certify that the well(s)was(were)abandoi ned in
County t.I Panel Identification No.(PIN) accordance with 15A NCAC 01C.0100 or'2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitudt and longitude in degrees/minutes/seconds or decimal degrees: •• i'
(if well field;.Ike laVsufficient)long is 9.Site diagram or additional well details;
3 5.223997 N —80.64325 w You may:use the back of this page to provide additional well site details or well
abandonnientdetails. Yen may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED I, !I
Attach well cot tractionrecord(s)ravailable.P+rmultipleinfectlonornon-water supplyrve&• SUBM TTALfNST1UJ�'17ONS
ONLY with th same construction/abandonment,you can submit one form
• 10a.For.All Wells: Submit this form within 30 days of completion of well
6a.Well IDIt abandonment to the following: I.
I II 1
:Division of Water Resources,Information Processing Unit,
6h.Total 4'ell depth: 410 l(ft,) r. 1617 Mail Service Center,Raleigh,NC 27699-1617
10b,For:infection Wells: In addition to1sending the form to the address ar 10a
6c.Borehole diameter: 6 (in.) .above,also submit one copy of this form'within 30 days of completion o'well
abandonment to the following.
I I
Division of Water Resources,Undergrannd Injection Control Progra
6t1.Water�rvei below ground surface 30 (ft) 'p'
i 2636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer eapinglesngth(if known): • " (:ti) 10e..T/or Water Supptti&Infection Went: hi additionto sendingthe form to the
il
addreas(ea)above,also snbtmt one copy of this form within 30 days of completion
1 of well abandtmment to the county health department of the count.). where
61.Inner casing/tubing length(if known): (ft.) • abandoned. i
'
6g.Screen length(if known): E (ft.) I 1.,
•• I.
Form GW-6 NorthCarolnaDepartm Envi
ronmental of Wateritesources Revised2- 2016
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WELL ABANDONMENT RECORD For Internal UN ONLY: 1 •
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1.Well a ntractor Information: WELL ABANDONMENT DETAILS '
Johnny Hart Jr . • I
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Conthetor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 IS needed. Indicate TOTALNUMBBR of
I wells abandoned: I
4446 B
NC Well ctdet,actor Certification Number 7b.Approximate volume of water remaining in well(s):20 (gal.)
1 5
1 Mc;call Brothers Tnc FOR WATER SUPPLY WELLS ONLY;
Company Name I HTH I.
7e.Type:of disinfectant used;
2.Well Construction Permit#: 10 014 R R 1 I j
List all applicable well construction penults(Le.UIC County.Stale,Variance,eta)tIlatown
7d.Amount of disinfectant used:
•3.Well uie(check well use): • •
t—_
Water Supply Well: l 7e.Sealing materials used(check all that apply):
❑Agticul'ual °Municipal/Publio D Neat Cement Grout ;®.Bentonite Chips or Pellets I
❑Gcothe, ial(Heating/Cooling SupplyjahResidential Water Supply(single) 0 Sand Cement Grout , 0 Dry Clay
❑btdustri 1/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout I 0 Drill Cuttings
❑lrrigatio 0 Specialty Grout : .❑Gravel
Non Watt+Supply Well: GT Bentonite Shiny I 0 Other(explain under 7g)
DMonitgring 4 °Recovery 1
Injection'well: ' 7f For cash material sblected above,provide amount of materials use •
OAquiferRecharge I DGroundwaterRemediation 2 BAGS
❑Aquifer Storage and Recovery • ❑Salinity Barrier 1
°Aquifer Test 0 Stormwater Drainage
°ExpetimeutalTechnology ' °Subsidence Control ' '
OGeother(ttal(Closed Loop) °Tracer • 7g.Provide a brief description of the abandonment procedure: I
❑Geothermal(Heating/Cooling Return) °Other(explain mider 7g) cH•LORINATE WELL. SLOWLEY POUR _
bbN I ON1.I t INl O WELLI,UNTIL I-ULI 2'.. •; '
i'
4.Date wfll(s)ab uhdened: 9/13/2024 r,1. d e024
.
Sn.Welt loeatiori: • U
CRP-WP OWNER'LLC �. • -, ;7-.;,:; -,, ,.. : l
8.Certification: r'Facility/OwncrNeme i Facility lD#(if applicable) �I d
12381 ALBEMARLE RD CHARLOTTE NC 28227' ' Il�� 9/16/2024
Physical Aldress,City,and Zip Signature of Certified Well Contractor or Well Owner Date
•
MECI LENBURG 111-201-07
By signing this form,I hereby cern:9 that the well(s)was(were)abandoned in
County ' I Parcel Identification No.(PIN) accordance with 1SANCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner. '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • I I
(if well field, ne laVloag is sufficient)
I 9.Site diagram or additional well details:
35.228951 N -.8 0.643 3 3 7 • �t You may.use the hack of this page to provide additional well site details or well
•
i 1'' abandonment details.You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SIhI31t4i T'1 AL INSTRUCTIONS Ri1CCIONS
Attach wellcdnstructiortrecord(s)Ifavailable.For multiple Olfaction ornonwatersapplywells
-'
ONLY with the same con truction/abandonme.nl,you can submit oneform.
I J 10a,For AB Wells: S bruit this fonn'within 30 days of completion of well
6a.Well Id#: I f abandonment to the folio 'ig: I u
;Division of Wa jerResoarces,Information Processing Unit,
6b.Total well depth: 84 (ft.) • 1617 Mall Service Center,,Raleigh,NC 27699-1617 4
! ' ' 10b.For injection Wells In addition to sending the form to The address in 10a
6e..Borehole diameter: 2 (in,) above,also submit one copy of this form within 30 days of completion of well
• j I. abandtnrrihentto the following: I
6d.Water.'level below ground surface: 20 (ft.) • • Division of Water Resources,Underground Injection Control Program,
I II 1636 Mail Service Center,Raleigh,NC 27699.1636
Ge.Outer e4inglength(if known): (ft,) 10c.For Water Supply Sr Injection Wells: In adrritionto sending the form to the
II address(4)above,also submit one copy ofiltis fonnwi8tm 30 days of completion
of well•abandonment 1? the county health department of the county where
6f.Inner easiIbhg/tubing length(if itnown': (ft.) .abandoned.
l ,
6g.Screet}length(if known): I (ft.) I
1
Font Gov-3b North Carolina Department ofF.nvironmental Quality.:;Division of Water Resources 0 Revised 2-2 14016
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