Iredell_Well Abandonment_20230515 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Alfred Kiesl i ng Jr 7a.For Geoprobe/DPT or Closed-L000p 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
3266-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
B & K Well Drilling Inc FOR WATER SUPPLY WELLS ONLY:
Company Name `t S w Chlorine
10 7c.Type of disinfectant used:
2.Well Construction Permit#: c20,23 - 20 11 0
List all applicable well construction permits(Le.01C,County,State.lrariance,etc.)ijknown
7d.Amount of disinfectant used: At a�
3.Well use(check well use): ` 1023
Water Supply Well: 7e.,Seating materials used(check all that appl lDtrOirf-:v% ,I ryr�Y
❑Agricultural ❑Municipal/Public Neat Cement Grout Bentonite Chips or PePlft ,�, Uri
❑Geothermal(Heating/Cooling Supply) PResidential Water Supply(single) ElSand 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)
❑Monitoring ❑Recovery,
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 ❑Stormwater Drainage 'l��!i �Yn'�✓�
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
79.Provide a brief description of the abauAent rocedure:
Jj!r'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) I G
4.Date well(s)abandoned: !J��Ijr .Z 3
5a.Well location: II
,yi� l,5L 1
Facility/Owner Name I�f) Facility ID#(if applicable) 8.Certification:
t3 S fl' lteu eu. AaY=5
Physical Address,City,and Zip Si aturc cn red Wcl r r ell Ow cr Date
*27�rl ���� By signing this form, /herebv certify that a wells) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A A'CAC 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]at/long 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.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-watersupp4•wells
ONLY with the same cansnwction/abandonment,you can submit one.fotm.
IOa. 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: 60 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection 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 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail.Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.For Water Supply&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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): M.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016