Mecklenburg_Well Abandonment_20230626

WELL ABANDONMENT RLCORD For Inteytnal c o LY:
This form can be used for single or multiple wells • Q r / t
1.Well Contractor information: WXLL AJ3A19MVNMNTD T
�` i G G I �� L'ern err
I `'^ c j h C�1 _ 7a.Number of wells being abandoned: _
Well r-ntracr rNam (or wellowncrpamona abandoning on llyabandonillhistherproperty) For multiple injection or non4vaier supply wells. ONLY with the ram,
consbvctionlabandonment,you can submitlane form.
NC Well Contractor Certification Number
- 7b.Approximate volume of water remaining in well(s):
� FOR WATER SUPPLY WELLS� f n ONLY:'�'ANk.A. (� rrlher 4 Sio�s Wed I�i�;��r fYaT.� ,Company Name 7c.Type of disinfectant used:- `,t1P ir-/t 'f AhO
2.Weil IConstruction Permit H: f OO 13 79 1 _
List all applicable nail permits li.e.County,Slate,Variance,Infection,etc.)il'known C ads' t
7d.Amount of disinfectant used:
3.Well use(check weil use):
Water Supply Well: 7e.dealing materials used(check all that appl
❑Ag'cultural ❑M icipa)/Public Neat Cement Grout ) entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) &Kcsidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(sharei 1) ❑ Concrete Grout ❑Drill Cuttings
❑It�i lion ;': '� ❑ Specialty Grout ❑ Gravel
Non-Water Supply Wells v�--��1 r R-.- ..,: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring pAmvery
7f
Injection Well: J I J t' J .For each material ae ceted above,provide amount of materials used:
❑AquiferReeharge ❑GroundwaterRemediation '� A" , ��(/
Aquifer Storage and d� ij 4 �f Spa i I ity artier❑ artier / / Z
bVVQi a Y
❑Aquifer Test ❑Storrnvwater Drainage
❑Experimental Technology DSubsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑"Ciacer —.
❑Geothermal(Beating/Cooling Return) OOther explain under 7
4.Date well(s)abandoned: 6✓/J 4 3 C L# ell t-
5a.Well location".
7W(2 ' " "- 9.Certification:
Pacility/Owned._,. Facility ID#(ifapplicable) . /
lcl�
-Val ��
Physical Address,City,and Zip f Signature of Certifi)Mall ntrector or well Owner Date
�i/( �i 27 _ By signing this farm, thereby certify that the well(s) was(were) abandoned ir.
/Co/u1nty�1- --� Parcel Identification No.(PlN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standard.
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees: 9 Site diagram or additional well details:
(if well field one)at/long is Sutlieicnt)
. A p ��t,t ��p��t-✓G/ Q, 1� You may use the back of this page to provide additional well site details or well
iae7 _ /�,1 •N (7 — ('f Sal abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUC IONS
Attach well eonsinie/ton record(s)if available. For multiple injection or non-water sup,-ly
wells ONLYu4th the same construction/ah(indontnenl,you can sttbmll one form. 1 Oa. For Ali Wells: Submit this form within 30 days of completion of well
abandonment to the following:
69.Well 1Dfl:
Division of Water Resources,Information Processing Unit,
i617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (fa)
106.For Infection Wells: in addition to sending the form to the address in 1Da
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: �/ �(in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface:' (ft,) 1636 Mail Service Center,Raleigh,NC 27699-1636
loc.For Water Suunly Injection We)Is: In addition to sending the form to
6e-Outer casing length(if known): - (D•) the address(es) above, also submit one copy of this form within 30 days om
completion of well abandonment to the county health department of the county
where abandoned.
6f.Inner easing/tubing length(if known):—(ft)
6g.Screen leng
th iflntown): (D')
North Carolina Department or Lnvironmen and Natural Resources-Division of Watcr Resources Revised August 201.
form GW�0

WELL ABA. DORM EN T RE( UKll For Internal Use ONLY- �
1.Well Contractor Lnforrnat[on: WE LA}ANDOIV�IENT DETAILS
flflu `
7a.For Geoprobe(iPT or Closcil Loop Geothermal Well having the same
Well Contractor Name(or well owner personally abandoning,well on hisiher property) well consh uction/depth,only 1 GW-30 is needed..Indicate TOTAL NUMBER of
Z-f 7 3 Q wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): �. (gal.)
FOR WATER SUPPLY WELLS ONLY:
T
CompahyNeine
7c.Type of disinfectant used:
2.Well Construction Permit m.
List all applicable well construction permits(4a.UIC.County.State.Variance.eta)f known 1" C�J
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply
t3Agricultuial Municipal/Public ❑Neat Cement Grout !11'Bentonite Chips or Pellets `
ClGeothermal(Heating/Cooling Supply) Okesidential Water Supply(single) O Sand Cement Grout t].Dry Clay
i7lndustrial/Commercial 011esidential.Water Supply(shared) 0 Concrete Grout !p Mill Cuttings
Ellni ation O Specialty Grout E)Gravel '
Non-Water Supply Well: 'd Bentonite Slurry E3 Other(explain under 7g)
OMonitoring ORecovery
Injection Well: 7f.For each material selected above;provide amount of materials used:
❑Aquifer Recharge C1Groundwater Remr diation
GAquifer Storage and Recovery ElSalinity Barrier , I
(3Aquifer Test UStounwater Drainage
[!Experimental Technology OSubsidence Control
Meothennal(Closed Loop) 1 lTracer 7g.Provide brief description o the abandon eat procedure:
QGeathermal LHca!jRg/CoqJin&Return) OOiher MEain under 7g)
4.Date weU(s)abandoned: l<J. (/ , er 4 „•
Sa.wen location: .e t
FacilitylownerNarpe' Tacititym(ifamucable) 8.Certilieadon: �80G
1 fin 1d4& 4111' THi;tlt �^sv cle� C, ZSv79 /�
� �/
Physical Ndd -.City.and Zip `-7 Stgoature of Certified Wen ontmoor or well Owner Date
'gGkta dir 1 �rg ` `��, ✓� By slpzing this firm.I hereby cer16 that the wells was were abandoned'in
county Parcel Identification NO.(PM) accordanci w ilk 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy ofthisrecord has been provided to the well owner.
56.Latitude and Longitude in dt�rees/minuteslseconds.or�decimol degrees:
(if well held,one lattlong 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.
CONSTRUC,ITONIfETAi<„fAS OF MZL S►BEING ABANDONED gt I1115TRUCCIONS
Attach weilconstrudionrecord(s)ifawiWle.Formuiuple0yedionornon-watersuppry-AvIls g� T
ONLY with the some constructioWa&mdonment you can submit one form.
10a.ft All Wells: Submit this forth within 30 days of completion of well
6a:WeIL ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: t0� (M) 1617 Mall Service Center,Raleigh,NC 27699-1617
10b.For Iniectlog,Welts-. in addition to sending the form to the address in 10a
6c.Borehole diameter: ?I (in,) above,also submit one copy of,this font within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: tc� j (g,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276991636
6e.Outer casing length(if known): (tL) 10c.For Water Sunoly&Injection Wells: In addition to sending the form to the
addresses)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):I U L l"t•- (ft,) abandoned
I
Gg.Screen length(if known): VA (1t.)
Form GW-30 North Carolina Deoartment oflinvimnn mmt ibmuty-niaeim,nf4rator 7� w..ww n e._t nn.