Iredell_Well Abandonment_20220830

WELL ABANDONMENT ItECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
• �� WELL ABANDONMENT DETAII[,S
5 Well Contractor 7a.Number of wells being abandoned:
Name(o well owner personally abandoning w Ion his/her property) For multiple it jection or non-water supply !veils ONLY ivirh the same
L\---L)-�,a _C_ co
ns
truction/abandonment,you can submit one form.
NC WelI Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
- (gal.)
t S ( FTypeof
PPLY WELLS ONLY:
Company Name 1 ^
�(�� ectant used:
2.Well Construction Per•mit#1: l �J
List all applicable well permits(i.e.County,State,variance,Injection,etc)if know-»
3.Well use(check well use): /V_
7d.Amount of disinfectant used: Z�dx.
—
Water Supply Well: 7e.Scaling materials used(cheep all that a 1❑Agricultural ❑MunicipaUPablic ❑Neat Cement Grout Pp Y)•
❑Geothermal Heatin Coolin ❑Bentonite Chips or Pellets
( g Su I Supply) esrdential Water Supply(single) ❑Sand Cent Grout
❑Industrial/Commercial fie/ ❑ Dry Clay
❑R idential Water Supply(shared) oncret.Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout
Non-Water Supply Well: ❑ Gravel
❑Monitoring ❑Recovery ❑Bentonite Slurry ' ❑ Other(explain under 7g)
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stotmwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 71;•Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) GI t��7/� , �.,,J G 4
-, �O•,/L•r�F' ,t�..l� �.al� r eta ✓.�Y�4.Date well(s)abandoned: — --� C_
5a.W 11 location:
Facility/Owner Name a- ^}
Facility IDM(if applicable) 8.Certifrcatio k ��t en.-5 47 p n
r ' 2� AUG 0 2022
'(/tl^ A�s�
Physical Address,City,and zip �^
y��� ( �q Catu—re
?1n
tor or Well�wners Date
����' 1 �(,�'7 4, !�O s:!3+<Ltil ! fDG v3Sft< U13'i{
County y signing this for in,1 hereby,cei r 1a��Vjl,
Parcel Identifindoned in
cation No.(PIN) accordance with 15A NCAC 02C.0100 oi--2C.0200(sWell Consbvctionwas 6vere) aStandards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and 1hal a copy of this record has beery provided to the well owner.
(if well field,one ladlong is sufficient)
35-- �� Q �) pp 9.Site diagram or additional well details:
! � N � b 6, �SO� You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS BEING ABANDONED
Attach well construction record(s)tf available. For multiple it jection or non-[rater supply SUBMITTAL INSTRUCTIONS
n sutbmi!arse form.
hells ONLY with the same constructiotdabandonntent,you ca
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
/ _ Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the forth to the address in 10a
6c.Borehole diameter: (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
,r—z,;N
6d.Water level below ground surface: (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft) IOc For Water Sunnlv&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
6f.Inner casing/tubing length(if known): —
(ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Dep
artment of Environment and Natural Resources—Division of Water Resources
Revised August 2013