Mecklenburg_Well Abandonment_20231024 (6)

WELL ABANDONMENT RECORD For Internal Use ONLY: ll
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1.Well Contractor Information: WELL ABANDONMENT DETAIIGS
Scott M. Werle
Y 7a.For Geoprobe/DPT or Close-dJ-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
wells abandoned:cnet'> I
3344-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.65 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS,ONLY:
Company Name 7c.Type of disinfectant used:
z.Well Construction Permit#: WM0301315&SIP#70003159
List all applicable well constriction permits(i.e.U/C,County,Slate,Variance,etc.)ifknoirn
7d.Amount of disinfectant used:G
3.Well use(check well use):
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Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heat inglCool ing Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout I ❑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)
MMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite —10lbs.
❑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 I
Pull well screen,abandon boring with benlonite chips and cover with cuttings
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 9/27/2023
5a.Well location: U L 1 ,� 21,23
Timothy Fridley N/A n,;,7:.-tii ,
Facility/Owner Name Facility ID#(ifapplicable) 8.Cc r' lion: �fte� ,.-'�}s• J i�t l
9905 Statesville Road, Charlotte, 28269
9.28.2023
Physical Address,City,and Zip Signature of Certified Well Con or or Well Owner Date
Mecklenburg 02509209
By signing this form, 1 hereby certify'that the ivell(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Constniction 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.I I
(ifwell field one IaUlong is sufficient) 9.Site diagram or additional well details:
35.356269 N -80.842170 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
A/tach well construction records)&,ailable. For nn ltiple injection or non-watersupply wells
ONLY with the same conrtiuctiomabandonnient,you can submit one farm.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: S B-01 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 5.0 (ft) 1617 Mail Service Ceiiter,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addit I n'to sending the.form to the address in 10a
6c.Borehole diameter: 3.25 (in) above,also submit one copy of this'form within 30 days of completion of well
abandonment to the following: I
6d.Water level below ground surface: 1.0 (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&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
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 5.0 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-20I6