Mecklenburg_Well Abandonment_20220930

WELL AHAtVDONMEM'RECURQ For bnternal Use ONLY:
1.Well Contractor Information: MLL ABANDONMENT DEIAII S
1 L kt� V-Wt+�1r t S 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
,� ' .. wells abandoned:
NC Well Contractor Certification Number /�� 7b.Approximate volume of water remaining in well(s): d
1 t"a4h U We�ii J-Pt/M R &d r FOR WATER SUPPLY WELLS ONLY:
T
Company Name �
` 7c.Type of disinfectant used:
2.Well Construction Permit#: 1 00 13 1
List all applicable well construction permits(i.e.WC,County,State,Parlance,etc.)ff nown
7d_Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials'used(check all that apply):
DAgricultural. OMunicipal/Public ❑Neat Cement Grout G1 entonite Chips or Pellets
ClGeothermal(Heating/Cooling Supply) residential Water Supply(single) 0 Sand Cement Grout ❑Dry Clay
0Industrial/Commercial gesidential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
01nigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry to Other(explain under 7g)
(7Monitoring- _---- - --ORecovery- I . -- - - -----
Injection Well: 7E For each material selected above,provide amount of materials used:
OAquifer Recharge ClGroundwater Remediation 25p,I i7 1(_5
ClAquifer Storage and Recovery ❑Salinity Barrier I
❑Aquifer Test OStormwater Drainage
Experimental Technology t]Subsidence Control 7g,Provide a brief descZ"I
onthe abandonment procedure:
DGeothermal(Closed Loop) []Tracer
17Geothermal(Heatin Coo. Return) OOther(explain under 7 ) W
Q T
4.Date well(s)abandoned:
LJ
Sa.fW�elll loocationy� S F P 3 !i
2022
FaciliWOwucr Name Facility 1D#(ifapplicable) 8.Certificadon: Ir)ii�i?i<^:2G:1 ,.�Sr�; Un;;t
rk% W 30G
7-10y7•`1 NrlurPAL/I& .Dt" cor1,o %,v5!JIGl 2-903
Physical.Address,City,and Zip Signature of Certified We Contractor or Well Owner Date
01—.(J? 1—10 By signing this form,I hereby cent fy that the wells)was(were)abandoned in
County _,— Parcel Identification No.(PIN) acconlmrre with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degreeslminutedseconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one latttong is sufficient) 9.Site diagram or additional well details:
N W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONS U(31ON DETAIM OF WELLS)BEING ABANDONED SIIBNDTTAL w—smeTIoxi
Altach well canshuction record(y)ifavailable.For multiple injection ornon-w0termrpply wens
ON,(:Ywith the same construction/abandonment,you can submit one form. 10a. ForAllWyls• Submit this form within 30 days of completion of well
6a.Well IDN: fQ abandonment to the following:
( Division of Water Resources,Information Processing Unit,
6b.Total well depth: 2,6)0 (ft.) 1617 Mall Service Center,Raleigh,NC 27699-1617
10b.For Inlection Wells: In addition to sending the form 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:
6d.Water level below ground surface: l C) (g,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if(mown): /X 00 10c.For Water Suanly&Injection WeUs: 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 where
611 Inner casing/tubing length(if known): R (ft.) abandoned.
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016