Mecklenburg_Well Abandonment_ (14)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information: WFi.I.ABANDONMENT DF.TAiD,S
JOHNNY BURR 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-Witter supply wells ONLY with the some
constructionlabandonment,you can submit one form.
A- 3098
NC Well Contractor Certification Number 7b.Approximate volume of water(remaining in well(s): 24.0 (gal)
GEOLOGIC EXPLORATION; INC FOR WATER SUPPLY WELLS ONLY:
Company Name "--�' -� � T GRANULAR CHLORINE
" ',w ype of disinfectant used:
2.Well Constriction Permit#: 10013295 �
List all applicable well construction permits(i.e.County,State,Yauian a .) aWnILV L
7d Amount of disinfectant used: F 3 OUNCES
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3.Well use(check well use): j'
Water Supply Well: ; 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mtmicipal/Public ❑Neat Cement Grout ❑Benttnnte Chips or Pellets
❑Geothermal(Heafing/Cooling Supply) OResidential Water Supply(single) ❑ Sand Cement Grout I ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: El Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery ----
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 37.25 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stornrwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 07/22/22
Sa.Well location:
CORROS RESIDENCE
Facility/Owner Name Facility IDR(if applicable)
8.Certification:
6431 SOUTH TRYON STREET CHARLOTTE 28217 k 07/29/22
Physical Address,City,and Zip Signature of Cenified Well Contractor or Well Owner Date
MECKLENBURG 167-221-01
By signing this farm, I hereby certify that the wells)was(were)abandoned in
County Panel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 9.Site diagram or additional well d tails:
350 09' 44.94" 800 54' 55.27" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(r)if available. For multiple injection or non-water supply
wells 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
6a.Well ID#: WSW-2 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
57.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
4.0 above,also submit one copy of this,,form within 30 days of completion of well
tic.Borehole diameter: (in.) abandonment to the following:
20•0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
where abandoned.
611 Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): 00
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Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013