Mecklenburg_Well Abandonment_20230419 (7)

WELL ABANDONMENT RECORD For internal Use ONLY:
1.Well Contractor formatio : C WELL ABANDONMENT DETAILS
lC�1C�U � J 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: i
NC Well Contractor Certifi Number 7b.Approximate volume of water remaining in well(s): (gal.)
CaA[ bJ—AarS I r1C( FOR WATER SUPPLY WELLS 0.NLY:
Company Name (q -�'LL
T 7a Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta)iflmown
7d.Amount of disinfectant used: O�i
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Benronite Chips or-Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑In al/Commercial ❑Residential Water Supply(shared) Concrete Grout ❑Drill Cuttings
ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount ofimate_'rials used;
❑Aquifer Recharge ❑GroundwaterRemediation U r-k ea-h-ely
❑Aquifer Storage and Recovery ❑Salinity Barrier APR I q
IM
❑Aquifer Test ❑Stormwater Drainage V
❑Experimental Technology ❑Subsidence Control ;� : ,; :•i 5:::.) •.s a
7g.Provide a brief description of the abandonment 06cidufe�
❑Geothermal(Closed Loop) ❑Tracer p.
❑Geothermal eating/Cooling Return) ❑Other lain under 7g CalLV:5 - C�•.t bYi r>a �.; `�'1
4.Date well(s)abandoned:
3,La I I ji�3 - V�WK ah
Sa.Well location:
Facility/Owner Name lity ID#(if applicable) 8.Certiticatio
F i
5)-3 A4
A-
Physical Ad ess,City,and Zip Signatrao of Certified Well Contractlir or Well Owner Date
By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
0-�• 2,iQg No-pia�R y 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.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)Ifavallable.Formultiple Injection ornon-watersupplywelk
ONLY with the same construcnonlabandonment,you can submit oneform. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well DNl• Z abandonment to the following:
f,, Division of Water Resources,Information Processing Unit,
6b.Total well depth: /o'er O (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I 10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter. V (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: D (fL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Suomiv&Iniection 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 where
6E Inner casing/tubing length(if known): (ff.) abandoned.
6g.Screen length(if known): (ft.)
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Form GW-30 North Carolina Department ofFnvironmental Quality-Division of Water Resources Revised 2-22-2016
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i
WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JeffreyGrant
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:Four
4328-B
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '1 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
WM0301273 7c.Type of disinfectant used:
List all applicable well construction pennits(i.e.UIC,County,State, variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout S Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
- -6Momtoring--- -- - [3Recovery--- - ---- — -- _-�- ___
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 ❑StormwaterDrainage Bentonite 40 pounds
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Fill the entire length of the borehole with Bentonite.
4.Date well(s)abandoned: 4-12-23
5a.Well location: APR 1 9 2023
Tuckaseegee Road Site
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: IU; ;;c;;: ,'•:Tl '^'�1 -'°'`' l�ii'S
720 Tuckaseegee Road, Charlotte, 2820890A_ �_�Y�� 4-12-23
Physical Address,City,and Zip Si nature of Certi ed Weil Contractor or Well Owner Date
Mecklenburg
By signing this form, 1 hereby certify that the ivell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100'or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.237098 N 80.869125 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Allach well conslniction recor (s)ifavailable.Ibrmuliiple ity'ection ornon-watersapply wells
ONLY with the saute construction/abandonment,you can submit onefonn. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: GW-1,2,3,4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 34 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:.1.5 (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: 30.26 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
30 (ft.) 10c.For Water Sunnly&Iniection 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 where
611 Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 4 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016