Mecklenburg_Well Abandonment_20220607

WELL ABANDONMENT RECORD "or ln%mi,Ucz ONLY:
'I'his form can be used for Single Or multiple aclls I
1.Well Contractor Information: RT.LL ABANDONJIENT DETAILS
M7a.Number of wells being abandoned:
r,,r t)­ oc;i� ONLY t�!,4
%VLT1 Cvn!r,�c!nr N�itne for cell o%%tier on . .%
2— 7 —A 7b.Approximate volume of water remaining in (gal.
\C CPVTr,.C1kr ccrinczxfic-n N�onn�cr
R/,Pl d4l"m FOR NNATER SUPPLY WELLS ONLY:
7c,Type of disinfectant used:
2.Well Construction Permit 3ot 2-
L7r aH 1,rt1p%:rmrf iPt.e.cwmfr,State, (t'. if
7d.Amount of disinfectant used:
3.Well use(check well use).
eater Suppl%Well: 7e.Sealing materials used(check all that apple):
Agriculiural ::MunicipalTablic Neat Cement Groto- Anionitc Chips or Pellet_
ZiGeothenral(Heating Cooling Supply) 5X�L;idcntiil Water Sitprily(single) Z: Sind Cement Grout DI, ,C in y
:1ndusirial'Commucial Mcsidentini Water Supply(shared) = Concrete Grow E Drill Cuttings
=,Specialty Grout 77 Gravel
Non-Water Supply Well: 73,ntottitc S41M. Othcr(ex!)1,1111 under 7u)
Monitoring —.Rcco%cry
Injection Well: 7f.For each material selected above.provide amount of materials used;
�,kauiNr Recharge =Groar&ater Renic-dillion s
ZAquifer Storage and Recox-cry —_Sn1irii!y Barrier
DAquifer Test S t om,.wa ter Drainage
--Experimental Technology —Subsidence Control 7g.Provide a brief description of the abandonment procedure:
—Geothermal(Closed Loci)) --lTracor
:]Geothermal(11cating'Cooling Return) 20ther(explain under 70
4.Date well(s)abandoned:
5a.Well location-
/v� -4"f ja S.Certification:
F
5 -2-,_')-2- Z-o
(Ati k&,rkq Li V&kj GigAk 6, 2-9?,l 3 ` , , I.
�V_ Co
PhVs;Ca1At3drC,s.C;t�.and Z41J signatu C.I U �7 0,WCH 0\%!�C' Dii,
By signing this four: I 011c).011r ceo-,ij'y that the icejkvl 1ta 4%ere) atiandoil-ca"fi
Couniv leC,­;tifjr3!!("!)Ne.(PIN) (I'mwelance-o4th IS,$ VC11C OG.01,00 or X 1)200 if'efl constmetion slarda"I.
t.,oj,v olthis)-eco,yj has heel;provider!to the ii ell o;tner.
5b.Latitude and longitude in degrees!minutes Neco nds or decimal degrees:
ffe01 Field.ore la,,11-2 i�Sufflc;='! 9.Site diagram or additional well details:
,
You may use the back of this pace to provide additicnal%%ell site details or wel
a ages if necessary.
W abandonment details. You niny also attach additional pa cccsqrn�
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
,n cm:,rmeri i ,,cord&j it ataPqh!v. For multiple injeclion fit,ron-rdo'cul 11.
t 7;ONL li'i;if,i tun co-fr-3to!; l0a. For Alt Submit this form mithin 30 days of completion of Nvel
e, n?1ton,lymdr-nmew,iou cat)vdmitnw I
6a.Well IWO: abandonment to the follo\%ing;
Division of Water Resources,Information Processing Unit,
IV,= 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total Hell depth:
10b.For Injection Wells' In addition to sanding the form to the address in 10,
1.1UN 0 7( 2027 above,also submit one copy of this forni within 30 day:of completion of wel 0— to foilo
6c.Borehole diameter; (in.) abandonment,
Division of NIVater Resources"Underground Injection Control Program,
6d,Water level below ground surface: -I'V"W OCVSSM 1636' -1636
MA Service Center,Raleigh, 27699
10c.For Water Supr)l*&Iniection Wells: In addition to sending the form u
L(
the address(es) above.'also submit one copy of this fbnri within 30 da%s 0
6c.Outer casing length(if known): —(ft.) F
completion of well abandonment to the county health department of the count
here abandoned.
6f.Inner casingltubing length(if knolln): (ft.)
6g.Screen length(if known): (ft.)
D.nmtmon!of Ent i;ortmn,Li;-..d Nattral Re4ources-Di%ision ofWa*cr R-snn-cec Revised AuEaist 201