Mecklenburg_Well Abandonment_ (4)

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 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-hater supply hells ONLY wilh the some
C —4421 construction/abandonment,you can subn it one form.
7b.Approximate volume of water,remaining in well(s): 5'S
(gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS:ONLY: `a t'
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z z; 1'
Company Name 7e.Type of disinfectant used: MAY
2.Well Construction Permit#: MA
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used
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3.Well use(check well use): !
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑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
❑lrri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7E 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#(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 this forin, 1 hereby certify that the well(s)was (were) abandoned in
Comity 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 well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hit/long is sufficient) 9.Site diagram or additional well details:
350 14' 09.24" 800 56 44.60' 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-waler supply
ivells ONLY with the same consiruction/abandonnlent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• AS-8 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 66.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection 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: 39.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
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
61:Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known):
i
Fonn OW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013