Mecklenburg_Well Abandonment_20220530 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor In rmta�n: WELL ABANDONMENT DETAILS
f
rJ 1 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Celli on Number 7b.Approximate volume of water,remaining in well(s): t" (gal.)
a,
f FOR WATER SUPPLY WELLS ONLY:
Company Name f 7T 1
7c.Type of disinfectant used: �l k 1
�d 7 2.Well Construction Permit#: zoo l2
List all applicable well construction permits(i.e.UIC County',State,Variance,etc.)ifknown y 'WAY
7d.Amount of disinfectant used: MA/ d \ r 3 n
3.Well use(check well use):i 2 22
Water Supply Well: 7e.Sealing materials used(check all that apply): `ri1�,�/��. 6Ig un'�
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ San ent Grout ❑ Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) Concrete Grout ❑ Drill Cuttings
Oh-rigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑A uifer Recharge ❑Groundwater Remediation D p-o
[]Aquifer Storage and Recovery ❑Salinity Barrier Gl n
❑Aquifer Test ❑Stormwater Drainage
El Experimental Technology ❑Subsidence Control 79,Pr vide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop); ❑Tracer r
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under 7 ) l pG
Irl"
4.Date well(s)abandoned: ;:r4
Sa.Well location:
a Le -f
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
-s 9
Physical Address,City,and Zip Signature of Certified Well Contractor or 11 Owner Date
By signing this form, I 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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field one lat/long is sufficient) 9.Site diagram or additional well details:
N W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construcIlay/bandonmeni,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a Well IIJ#: oA abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:. ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
(/n 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: r (in.) above,also submit one copy of this form within 30 days of completion of well
to abandonment to the following:.
6d.Water level below ground surface: Ali (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g) 10c.For Water Supply&For Water &Injection Wells: In addition to sending the form to 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
611 Inner casing/tubing length(if known): '9"rt (ft) abandoned.
6g.Screen length(if known): / (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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P itiiitToConductRepairC}r�bandori Pager I of:1
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Meeklenbutg Countyi;teaiih Depaifinenf';
Grouridwater B��Jastewater Servic6s`
3205"Freedom Dr We 8000;
ChadottdJN';C 28208 a .)
Phone (880)31k 9tit34
Faz:(704�33Ei-6884,
PERMIT t, CONDUCT MAJE}R REPAIR AND10R-ABANDON A,WATER"SUl?PLY'WEL'L
Perm00'.. 10D12967 Fife;# 113448' Tax Parcel#: 037224=27
Property
Jab Location Address 5515 LABORDE AVE
City/ETJ;�HARLOTI"E . State t5C Zip Code:. 28269
Pes mkt,tsuance,,Date 3/2112022
use©fiWell Nta
Type of Facility Servedby.INetl House;
Project Type`.:Abandcinrrient;
rea of.Re Mated Gro.undwafer Usage Review 'YES:
the Water Supply'YVeil repair or,abandonment,rrtust meet all requirements set forth in the:
Meckte!7b Ct?ur ty Groundwat6f lNet1 Regutaft0 and any other applicabk:rufes and laws,-
A No#E�Carona Crtified�Well Contractor must perforrri the well construe#ion activities.;
• Repair of aty Water Supply Weil vsrtth the well head terminating below ground surface(buried.seal)
shall-Include extending=fete=veil c sing at'leasf. u+relve�richas:above. ie surface..
Phis:Permif'shall,be VALID fora period not to ecee 12 man"ths frtirr%'the.d€te ti€_issuance.
Spgcttic CQnditrons of This.Perrrttt(Ghenk all that apply).
Grout.rnust be placed the full extent of tfie casing:
0 Initial water sample to talon and analyzed for46hedk all that apply)
1/titaUlp Ofgantc,Compounds.{VO 's} ,Semi votat�te Compounds f Metats;(Spa cify in.Qther"Conditions)
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t'eshcJees' 0.
0e061,des, n,
Other{See Seiow)
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Other Conditions of Thl%Permit:.
None
Authonz d Agerti ,Runt N' OvnerlLegai;AgenC Pnnt Name:
s! a uret, Signature.
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