Mecklenburg_Well Abandonment_20230706

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Con ctpr,Information: WELL ABANDONMENT DETAILS
6 l�ire e a 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally dandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well C`onnnact�or7 orLfiration Number 7b.Approximate volume of water remaining in well(s): (gal.)
a f FOR WATER SUPPLY WELLS ONLY:
Company Name
t� �^ 7c.Type of disinfectant used:
V G l J
2.Well Construction Permit#: 0 U
List all applicable well construction permits(i.e.UIC,County,State•Variance,etc.)ifknown y
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 ❑ Bentonite Chips or Pellets
❑Geothermal(Heating(Cooling Supply) ❑Residential Water Supply(single) ❑ Sandd n e�nt Grout ❑ Dry Clay
❑IndustriallCommercial ! /❑ esidential Wnater Supp shared) on�'C Crete Grout El Drill Cuttings
Irrigation❑ L C_ CCU�C� ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7£For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 2
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g•Provide a brief description of the
abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) G� I.I6S eJ JT`'f C r�1 x—n�> .-
4.Date well(s)abandoned: D a I�J� V t 6=20 +M
,J 0l'23
Sa.Well location:
Facilitf/OwngrName // Facility ID9(ifapplicable) 8.Cer�---
Physical Address,City,and Zip Signanueortified Well Contractor or Well Owner Date
C G� B signing this on,% I hereby certify that the wells was were abandoned in
y � g f y ly lJ (were)County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one latAong 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.
CONS TRUCii!ON DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)travailable.For multiple injection ornon-water supply wells
ONLY with the some cons[ruction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID##: abandonment to the following:
1� Division of Water Resources,Information Processing Unit,
6b.Total well depth: (fL) 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: (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: IL14 (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC.27699-1636
6e.Outer casing length(if known): (R,) 10c.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
6£Inner casing/tubing length(if known): O tiQ ( ) abandoned.
6g.Screen length(if known): d(L2 A)
Form OW-30 North Carolina Department of Envirormtental Quality-Division of Water Resources Revised 2-22-2016