Mecklenburg_Well Abandonment_20220530 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For mulliple injection or non-water supply ive//s ONLY wilh the same
C - 4421 conslruction/abandonmem,you can submil'one form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 5'S (gal.)
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS OINLY:
Company Name 7c.Type of disinfectant used: c G hf r r
2.Well Construction Permit#: MAY V J 9 n ?n q
List all applicable well construction permits(i.e.County,State,irariance,etc.)ifknoa'tt l'z[
7d.Amount of disinfectant used:_
3.Well use(check well use):
t,AIQ/L
Water Supply Well: 7e.Sealing materials used(check all that apply): "" OG
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: El Bentonite Slurry ❑Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 10.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 03/18/22
5a.Well location:- - _
THE PARKING SPOT
Facility/Owner Name Facility 1139(ifapplicable) 8•Certification:
6210 WILKINSON BLVD CHARLOTTE 28214 �'"'�'� "'"' 03/30/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
MECKELNBURG By signing thisfornt, 1 hereby certify that the well(s)was (were) abandoned in
County Parcel Identification No.(PiN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 9.Site diagram or additional well details:
350 14' 08.83" 800 56' 44.26" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For mulliple h jection or non-water supply
wells ONLY with the same construction/abandmnneni,you cmv submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
AS-5 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
64.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
38.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Sunnly& Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): A) the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
I
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abando ned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the saute
construction/abandonment,you can submit one form.
C - 4421
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 5.5 (gal.)
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS ONLY: J
Company Name
7c.Type of disinfectant used: � I
2.Well Construction Permit#: MAY 3 0 20
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used:
2Z
a•
3.Well use(check well use): U
Water Supply Well: 7e.Sealing materials used(check all that apply): LOG
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: IRE For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 10.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 03/18/22
5a.Well location:
I
THE PARKING SPOT
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
6210 WILKINSON BLVD CHARLOTTE 28214 ""°"` 03/30/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
MECKELNBURG By signing this fonn, I hereby certify that the ivell(s)was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 14' 09.39" 800 56' 44.01" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
we/ls 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 ID#: AS-7 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 64.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 37.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection 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
completion of well abandonment to the county health department of the county
where abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013