Mecklenburg_Well Abandonment_20230602 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.We ontracctor InfMwjv
on: WELL ABANDONMENT DETAILS
ar )3 7a.Number ofwelis being abandoned-
Well
Contractor Name(or well owner pe onally abandoning well on his/her property) For ntulnple or ton-water supply we ONLY with the some
construcoombbandonment,you can submlil one form. •�
NC Well Contractor Certification Number 7b.Approximate volume of water re I airing in well(s): I (gal.)
FOR WATER SUPPLY WELLS ONLY: 1 ,
Company Name p 7c.Type of disinfectant used:
2.Well Construction Permitm. I 0 Ldrtall applicable well permils(i.e.County,Stare,irariance,Injectian,ere.)iflmmm 7d.Amount of disinfectant used: 2- j i n-L
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Hearing/Cooling Supply) t entiai Water Supply(single) 0 Sand Cement Grout ❑Dry Clay
+��
❑lndustrial/Commercial ❑Residential Water Supply(shared) �crote Grout ❑Drill Cuttings
OIrri ation ❑Specialty Grout ❑Gravel
Non-Water Supply'Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material sel red above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation �i G.0 I
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
OF—xperimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ��� -[�i' �/ �:> B!tr�� �• �J l(repY
❑Geothermal(Heating/Cooling Retain) ❑Other(explain under 7g)
d.Date well(s)abandoned:
•-ti
58.Well location- JUN G 2 2023
1e,ndg U,L
Facility/Owner Name
L Facility lD#(ifappricable) 8.Cerd do Ir �S7,__ii^1 �i: yitTarr l�ro
Physical A dress,City,and Zip Signature o Contractor or Well Ownec Date
By signing thisform. I hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has beery provided to the well Mmer:
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details-
u-) 3- Z, N ag O —7S 1 .) You may use the back of this page to provide additional well site details or well
r r W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Aaach well caustntction record(s)if available. For multiple h jection or non-crater supply
wells ONLY trilh[lie same co mtruction4abandonnient,you cart submit one form. 10a. For All Wells• Submit this form within 30 days of completion of well
6a.Well IDN: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: bp (it) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
�O (in.) above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: abandonment to the following:
e ?
6d.Water level below ground surface: 30 it Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Smmnly&Injection Wells: In addition to sending the form to
be 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
6f.Inner casing/tubing length(if known):_ where abandoned.
_ � I
6g.Screen length(if known): (ft)
i
Form G%V-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

WELL
ttDAND NYM a RECORD Forintemal Usc ONLY:
This form can be used for single or multiple wells
1.Well Contractor Inf motion: WELL ABANDONMENT DETAIIS
k"' `1r) 1 0 xv 7a.Number of wells being aband Ined:
Well Contractor Name(orwell own ersonally abandoning well on his/herproperty) For mu/nple injection or trors-uiater soppy wells ONLY rvirh the some
constmetlonrabandonment,you can sub i it nne fo—
LA 3,3 C,NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): _(gal.)
u�(j ���il t l s - FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable ivell permits(i.e.County,State,Variance,Injection,etc)jlmmvu 7d.Amount of disinfectant used: 2 K 6
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) kWeest dal 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'%Vell: ❑Bentonite Slurry er(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,pro de amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief fescription of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer �y t
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 3
4.Date well(s)abandoned: �6:I I Z3
So.Well location: F'� rr h F` 'I,
M�." �..c.C \d h�ffiad
^ L Quv ?UN (► !r 2023
Facilitylowner Name ii,,__ Facility ID#(if applicable) 8.Certification:
S 20 ( ��lt.��uJl MKS Did +A IV L {r,`�s�,- ��Jr:L 3
Physical Address,sty,and Zip U Signature of CcrfificCOXsiftractor or Well Orwer` Date
mac,e, fnluf i 13' S 1 "tO ay signing this form, I hereby certi,that the wells)was(were)abandoned in
County Parcel Identification No.(PIN) accordmrce ivith 15A NCAC 01C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided io the well(tuner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
Z�P �� You may use the back of this page to provide additional well site details or well
3 N .[Z� • ti 7 W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)#available. For multiple injection or nan-water supply
wells ONLY with the same cmtstractionrabandountenr you can submit one form. 10a. For All Wells Submit this form within 30 days of completion of well
6a.Weil WN: a 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 Iniection Wells: In addition to sending the form to the address in 10a
3 above,also submit one copy of this form within 30 days of completion of well
6c Borehole diameter: (in.) abandonment to the following.
e
6d.Water level below ground surface. ?i a..-(ft) Division of Water Resources;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&Iniection Wells: In addition to sending the form to
6e.Otter casing length(if known): (v {ft the address(cs) above, also submit one copy of this form within 30 days of
� ��,,�� completion of well abandonment to the county health department of the county
6f.Inner casing/tubing length(if known): 1/j�(ft.) where abandoned.
6g.Screen length(if known): NIT (ft)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013