Mecklenburg_Well Abandonment_ (12)

WELL ABANDONMENT RECORD For Internal Use ONLY;
r Inf madon:1, Contracto I 4. WELL ABANDONMENT bETAILS "
7a.For Geoprobe/DPT or ClosediLoop Geothermal Wells having the same
Well Contrac r Name(or 1 owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed, Indicate TOTAL NUMBfiR of
wells abandoned:
NC Weil Conttlactor Certification Nu ber �+ 7b.Approximate volume of water remaining Ih well(s): (gal•)
FOR WATER SUPPLY WELLS O Y:
Company Name t
7a Type of disinfectant used:
2.Well Construction Permit#: g+p
. Well use(check well use):
List all applicable well construction (i permits .e.UIC,County,State,Variance gt c . C .1�1.nt of disinfectant used V
� aco'u
. ��
Water Supply Well: Ai�(; ! 517sealing materials used(check all that apply):
❑Agricultural ❑Mum al/Public Q NeahWent Grout ntonite Chips or Pellets,
t5,
❑Geothermal(Heating/Cooling Supply) sidential Was�plgesing�l�) Sand Cement Grout ❑Dry Clay
to tr..lr
❑Industrial/Commercial ❑Residential Water Supply ared) ❑ Concrete Grout ❑Drill Cuttings
[]Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
T"Jecdon Well: 7E For each material se�ted,above,provide amount of materials psed:
❑Aquifer Recharge ❑Groundwater Remediation Z V_ -1 - r G'
❑Aquifer Storage and Recovery ❑Salinity Barrier �'/.
Aquifer Test ❑Stormwater Drainage
0Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(H-eating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)•abandoned: Ze V G
r
5a.Well location:
Facility/Ownnerr,Name
�A cility ID#(if applicable 8.Certific
ation,
�0I)A� �� �� zH/'
Physical dress,City,and Zip Signature We ntractor gr Well Mier Date !/`
[9 By signing this form,I hereby certify that the well(s)was (were)abandoned t
.:County Parcel Identification No.(PIN) accordance with 1 SA NCAC 0.2C.0100 or 2C.0200 Well Construction Standar;
and that a copy of this record has been provided to the well owner.
Sb:Latitude and loligitude In degrees/minuteslseconds or decimal degrees:
(if well field,one lat/lodg is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to.provide additional well site,details 41well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION(DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructiO records)ijavailable.For multiple Injection or non-water supply welts
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
61f.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
66i Total well depth:.
10b.For Inlection Wells: In addition to sending the form to the addfcss in I0a
above,also submit one copy of*s form within 30 days of completion of well
-6c:B6reh6le diameter: .(in.) abandonment to the following:
6d.Water level below ground surface: N" (ft) Division of Water Resources,Underground Injection Control Program, i
1636 Mail Service Center,Raleigh,NC 27699-1636
length if known); (rt.) loc.For Water Sunuly&Iniec'tion Wells: In addition to sending the form to the
6e.Outer casing g ( ) 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.
6E Inner essing/tubing length(if known): (ft.)
length Of known):
`.6g.Screen 1gt .(i ,
i
Revised 2-22-21
Furm GW.30 North Carolina Department of Environmental Quality-Division of Water Resou'as I