Mecklenburg_Well Abandonment_20230515

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Alfred KIeSIICIg Jr 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
3266-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
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B & K Well Drilling Inc FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorine �`'' w•o- "y"��"
7c.Type of disinfectant used:
2.Well Construction Permit#: 13(p 7-1 mmy 1 ZQ23
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.)ifknorvn �� l�
7d.Amount of disinfectant used: '� o t'iv-r�,i1� r,f, ,
3.Well use(check well use): (.•iu_^ a
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public -EYVJ at Cement Grout -ErIfe-ntonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) sResidential 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)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation /
fi !7/-6 1
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control s�
7g.Provide a brief description of the abandonment p cedure:
❑Geothermal(Closed Loop) []Tracer /} /
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) �/� C,(>.^ul 15
4.Date well(s)abandoned:
a.Well location:
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Facility/Ownel Name Facility ID#(if applicable) 8.Certification:
7-7,loo0 'Corrc,ncx 0rnP\tiuS
Physical Address,City,and Zip Q Zbk3lighaturc of C ificd Well Cont actor o�Wel' Date
G '��hu�trq 5 Io is By signing this form, 1 hereby ce :at the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C. 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.
(ifwcll field,one lavlong 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 tmrstntctionrecotd(s)ifavailnble. For multiple injectionornon-waterstipp(vwells
ONLY with the samr constructionlabandonment,you can submit onefonn.
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 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: 3-o (ft,) 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 Supply&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 where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.) j
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016