Mecklenburg_Well Abandonment_ (9)

.J Lam" �I"• v
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS i
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some
Wed Contrac or Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number
7b.Approximate volume of water.remaining in well(s): (gal:)
77
FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: J I
List all applicable well constn(ctlon permits 6.e.UIC,County,State,Variance,etc.)(fknoaat 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all.that a;rentonite
'
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ❑ Sand Cement Grout [3 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Beritonite Slurry ❑ Other(explain under 7g)'
❑Monitoring ❑Recovery
Thjectlon Well: 7E For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemedietion j ire i / ,2
.❑Aquifer Storage and Recovery ❑Salinity Barrier
17Aquifer Test ❑Stormwater Drainage
❑Experiments)Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Look ❑Tracer /'t���� n/� j.t► �� �U/ JO /!�
❑Geothermal(H-eating/Cooling Return) ❑Other(explain under 7g)
A.Date weli(s)-abandoted:
5a.Well location:
UM
Facility'/AwnerName acility ID#(if applicable) 8.CeC cation:
Physical Address,Cj ,pnd Zip �� Signature of Ce ed Well Contractor or Well caner Date
)_ J By signing this form, I hereby cer16 that the'well(s) case (were) aband ed in
County Parcel Identification No.(PIN) accordance with I SA NCAC OlC.AI00'or 2C.0200 Well Construction StaIi¢ards
and that a copy of this record has been provided to the well owner.
5b:Latitude and lolrgitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(lorig is sufficient) V 9.Site diagram or additional well details:
�� You may use the back of this page to provide additional well site details or well
If ,, / ' N �' abandonment details. You may also attach additional pages if necessary.
..,__.._-_ET TLS OF WELL(Sl BEING ABANDONED SUBMITTAL INSTRUCTIONS
rittaod well constructlotIrecord(s)(faval/able.For multiple irylectionor non-water supptywe/ls
ONLY with the same�corystruction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
I ' abandonment to the following:
6a,Well fD#:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
66:Total well depth:. (ft.)
10b.For Injection Wells: In addition to sending the form to the address,in l0la
above, also submit-one copy of this form within 30 days of completion of well
'6c:Bbrehole diameter: (in•) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 3 (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
7
l0c.For Water Sunaly&Inject[on Wells: 1n addition to i sending the form le the
6e.Outer casing length(if known): f (ft•) address(es)above,also submit one'copy of this form within of days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): _(fk) abandoned.
II
6.g.Screen length•(if known): f II
•Furor t3W+30 f Revised 2-32-2016
North Carolina Department of Environmental Quality-Division of Water Resources III