Cabarrus_Well Abandonment_20230915

WELL ABANDONMENT RECORD For Internal Use ONLY:
-
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Daniel Summers
7a.For.Geoprobe/DPT or Closed-Loop Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 isineeded. Indicate TOTAL NUMBER of
wells abandoned: 1
2579-A
7b.Approximate volume of water remaining in wells 2.16 al
NC Well Contractor Certification Number PP g O' (g )
Carolina Soil Investigations, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
WM0301285 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well constriction permits(i.e.UIC,County,State,variance,etc.)ifknown
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 a Neat Cement Grout i ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential 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)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation neat cement 92.85 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer tremie grouted with neat cement
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 08-30-23 IN tp---U 17-1 V C.L:
5a.Well location: S E P 1 5.2023
Former Bost Realty
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: `}►��.pt ZTIr�r`� �'�" fir?
806 South Main St Kannapolis, NC DWOMOG
[)'J ��, 0 30-23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Cabarrus By signing this form, 1 hereby certify that the ivell(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
-80.62805 You may use the back of this page to provide additional well site details or well
35.48455 N
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavatlable.For multiple injection or non-water supply wells
ONLY with the same consiruction/abando nment,you can submit one fonn.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-1 abandonment to the following:
I
Division of water Resources,Information Processing Unit,
6b.Total well depth: 32 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6" (2"Well) above, also submit one copy of this,form within 30 days of completion of well
6c.Borehole diameter: (in.)
abandonment to the following:
6d.Water level below ground surface: 18.5 (ft) Division of Water Resources,I,Uiiderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
ti
17 10c.For Water Supply&Infecti i on Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
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.
1
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016