Mecklenburg_Well Abandonment_20220815 (2)

WELL ABANDONMENT RECORD For Internal Use 0 LY:
1.Well Contractor Information: WELL ABANDONMENT
Howard L Rushing, Jr. 7a.For Geoprol e/DPT or Closed-hoop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hisilicr property) well constructio depth,only 1 OW-30 is needed. Indicate TOTAL NUMBER of
3342•A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water retraining in well(s): 0 (gal.)
Carolna Well Drilling FOR WATER IUPPLYWELLSONLY:
Company y Name 10013278 7e.Type of disinfectant used: 70 o HTH
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,Coun(v.State,t-ariance,etc)1(knonn
7d.Amount of isinfectant used: OZ
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) O Sand Cement Drout ❑Dry Clay
❑Industrlal/Commercial ❑Residential Water Supply(shared) O Concrete Grot it ❑Drill Cuttings
❑Irri ation ❑Specialty Gro it ❑Gravel
Non-Water Supply Well: ❑Bentonite Sin ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each ma erial selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 31 ) 50 b Bags
❑Aquifer Storage and Recovery ❑Salinity Barrier
OAquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide e b of description of the aband eithp > ': �E0
❑Geothermal(Closed Loop) ❑Tracer Chlorinated Well �` 9 �!
❑Geothermal(Heatin Coolie Return ❑Other(explain under 7 ) �..
Poured ( y 1 ) Bags Bentonite Ph i ti OLI
4.Date well(s)abandoned: 8/02/2022 --� j tr^ it9 r"
Sa.Well location:
The Trust Of Ruby Hucks Cook
Facility/Owner Name Facility ID*(if applicable) 8.Certification)
7602 Oliver Hager Road Huntersville, NC 28078 phw�,L �-- 8/06/2022
Physical Address,City,and Zip Signature of Certi red Well Contractor or Well Owner Date
Mecklenburg 009-381-03 signing this orm, I hereby cerlibp that the wells n•tts were abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Consmictlon Standards
and that a cop)ol'this record has been Provided to the well owner.
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if%veil field,one lat/long is sufficieni) 9.Site dlagra or additional well details:
35.24.440 N 80.54.1 80 W You may use the back of this page to provide additional well site details or well
abandonment d tails. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(r)ltravallable. Pop nrulrfple hyection or rton-water•supplr%•ells
ONLY with the some constructioitlabmidonniettt,you ran submit one.firer.
10a. For All 'ells: Submit this form within 30 days of completion of well
6a.We111Dq: abandonment to the following:
t DIAl lon of Water Resources,Information Processing Unit,
6b.Total well depth: 110 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
IOb.For Ini tion Wells: in addition to sending die form to the address in 1 On
6c.Borehole diameter: 6 (fn.) above,also W)mit one copy of this form within 30 days of completion of well
abandonment t4)the following:
6d,Water level below ground surface: 29 (ft,) Division of Water Resources,Underground injection Control Program,
636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Wet r Sunift&Inlection 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 abatic onment to the county health department of the county where
6E inner casing/tubing length(if known): (n,) abandoned.
6g.Screen length(if known): (fL)
Form GW-30 North Carolina Department of Environmental Quality-Divi¢ion of Watcr Resources Revised 2-22-2016
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WELL ABANDONMENT RECORD ForIrrtcrml Usc 0 LY:
1.Well Contractor Information: WELL AB NT DETAILS
Howard L Rushing, Jr.
7a.For Geopro e/DPT or Closed-Loop Geothermal Wells having the seine
Well Contractor Name(or well owner personally abandoning well on hisiber property) well construction depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
3342 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining In well(s): 0 (gal.)
Carolna Well Drilling FOR WATER UPPLY WELLS ONLY:
Company Name 70% HTH
2.Well Construction Permit#:
10013277 7c.Type otdlsl fectant used:
List all applicable utll comirwilou perinits(i.e.UIC,County.Staie,i'ariance,etc.)ijknown
7d.Amount of disinfectant used: 80Z
3.Well use(check well use):
Water Supply Well: 7e,Sealing materials used(check all that apply):
❑Agricultural OMunicipal/Public ❑Neat Cement Grout N Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) O Sand Cement Orout ❑Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) ❑Concrete Gro t ❑Drill Cuttings
❑Irri ation O Specialty Gro it ❑Gravel
Non-Water Supply Well: ❑Bemonite Stu ry O Other(explain under 7g)
OMonitoring ❑Recover)'
injection Well: 7L For each ma erial selected above,pro%ide amount of materials used:
OAquifer Recharge ❑Groundwater Remediation 30 ) 50 b Bags
OAquifer Storage and Recovery OSalinity Barrier
OAquifer Test OStormwater Drainage
OExperimental Technology OSubsidenec Control 7g,Provide a b I of description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer Chlorinaed Well
OGeothemtal(Heating/Cooling Return) ❑Other(explain under 7 )
f�
Poured ( 0 ) Bags Bentonite RECEIVED
4.Date well(s)abandoned: 8/02/2022
ga.Well location:
Jack R Harley ' tt
Facility/Owner Name Facility ID#(if applicable) 8,Certification, �l y��`'
15510 NC Hwy 73 Huntersville, NC 28078 &w . A ,t2e�y 8/06/2022
Physical Address,City,and Zip Signature of Certified Well Contractor of Well OwneY Date
Mecklenburg 009-381-06 a signing this vrm, !hereby certi that the wells ryas were abandoned in
g J Ji () (were)
County Parcel identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constriction Standards
and that a cop)-�/'this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is suttcient) 9.Site diagram!or additional well details:
35.25.550 N 80.54.250 W You may use tlje back of this page to provide additional well site details or well
abandonment dtftatls. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL NSTRU TC IONS'
Atiacii well consiracdori record(s)tt(avallable. ror niuldple it fectiott or noti-water stipph-tirlLs
ONLY with the some construction/abandonment,you can submit one firm.
10a. For All 'ells: Submit this form within 30 days of completion of well
6a.Well iD#: abandonment tothc following:
Gt Division of Water Resources,Information Processing Unit,
6b.Total well depth: 125 (ft.) 1�l7 Mall Sertice Center,Raleigh,NC 27699-1617
10b.For Inice ion Wells: in addition to sending the form to the address in 10a
6c_Borehole diameter: (tnJ
above, also sutmit one copy of this form within 30 days of completion of well
abandoruuent tc the following:
6d.Water level below ground surface: 26 (ft.) Division of Alater Resources,iUnderground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.For Witte Supply&Injection Wells: In addition to sending the form to the
address(es)abo•e,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E inner,cosing/tubing length(if known): (ft,) abandoned.
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6g.Screen length(if known): (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Divis on of Water Resources Revised 2-22-2016
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