Mecklenburg_Well Abandonment_20231101

1.Well Contractor Informa•on: WELL ABANDONMENT DETAILS
��]�h 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well an his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
��� wells abandoned:
�`
Contractor Certification Number 7b.Approximate volume of wa Ir i•emaiiiing in well(s):
NC Well C
�- , FOR WATER SUPPLY WELLS ONLY-
'Company Name �-� 7c,Type of disinfectant used: 1 1 t l
2.Well Construction Permit#: �b' //M -
List all applicable well construction permits Co.e.UIC,Couur)�State,Variance,etc.)y7oomi
7d.Amount of disinfectant used: J
3.Well use(check well use);
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mu pal/Public ❑'Neat Cement Grout enwnite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) W1 esidentialWater Supply(single) Cl Sand Cement Grout ❑Dry Clay
❑Indtistrial/Commercial - ❑Residential Water Supply(shared) M Concrete Grout ❑Drill Cuttings
Olrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovcry
injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 3 hf ��
•.❑Aquifer Storage and Recovery ❑Salinity Barrier
17Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence.Control 7g,provide a brief descri lion of the abandonment procedure:
❑Geothermal(Closed Ldop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date weli(s)•abandoned:SR.Well location: ` / �y y�1y 1 2`t123
'
l
. ..-
FecilityL 8 Ce tification:
OwnerNome FacilitylD#(ifa plicable)
Phvstoai"'.-tress,City,and Zip Signature of ertified Well Contractor of Well Owner Date
9y signing this form,I hereby,'certo that the wells)was (were)abandoned in
• County Paicel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
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:
(if well field,one Int/lodg is sufficient) 9.Site diagram or additional:well details:
,11 p��.j J 1 N �A W You may use the back of thisipage to provide additional well site details or well
b t�1 7 "1 , abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructiol records)ifavailable.Formulliple injection or no-watersupply wells
ONLY with the same ed1winrclion/cbandonmW,you can submit oteforon' 10a. For All Wells: Submit this form within 30 days of completion of well
6a:Well ID#• A abandonment to the following:
Division of Water Resources,Information Processing Unit,
615:Total well depth:. / —(ft.) 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Infection Wells: lit 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:
6t1;Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
lOc.For Water Supply&Iriiection Wells: In addition to sending the form to the
6e.Outer casing length(if known): ' (ftJ 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
�f,� abandoned.
6f.Inner casingltubing length(if known): r._.�C1--Y
6g.Screen length(if known):
• � Revised 2-22-2016
Furm GWJO North Carolina Department of Environmental Quality-Division of Water Res aigrcrs ,

Y T 3JJJALJ ZX"Z'J.L•Jv vi.a,a..._.i. a..... �. I. ........... ......__. I
1.We11 C ntractor Information: WELL ABANDONMENT DETAILS
i
7a,For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
Well Contractor Na a(or well owner personally abandoning well an his/her property) wells� abandoned:
umber 76.Approximate volume of'Water'remaining in well(s):
NC Well Contractor Certification (gal•)
FOR WATER SUPPLY WELLS ONLY:
Company Name �' 7c.Type of disinfectant used: r14
2.Well Construction Permit#:1uG'l /5�
List all applicable well construction permits Q.e.UIC, mo%State,Variance,etc.)Thnowrr 7d.Amount of disinfectant used: PZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
OAgricultural ❑Municipal/Public ❑Neat Cement Grout Wentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) gW,'idential Water Supply(single) D Sand Cement Grout ❑Dry Clay
❑Indtistrial/Commercial OResidential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
D Gravel
OIrri ation D Specialty Grout
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring DRecovery
Injection Well: 7E For each material selected'above,provide amount of materials used:
❑Aquifer Recharge DGroundwaterRemediation h.
•.❑Aquifer Storage and Recovery OSalinity Barrier
DAquifer Test DStormwater Drainage
❑Experimental Technology OSubsidence.Control 7g,provide a brief dessri lion rof�the abandonment procedure:
❑Geothermal(Closed Ldop) OTracer r"dh'r
n f 11
❑Geothermal(Heating/Cooling Return) OOther(explain under 7g) ;T
4.Date well(s).abandoned: ILI c+' -� in%/ a )nnn
SagWelllocation!,�
Facility/Owner Name Facrli iD#(if applicable)
8.Certification:
Physical Addrass,City,and Zip Signature of Certified Well Contractor of Well Owner Date
h. (_� By signing this form,1 hereby cent that the well(s) was (were) abandoned lit
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has'been provided to the well owner.
iV.Latitude and longitude in degrees/minutes/seconds or decimal degrees: !
(ifwell field,one lat/lotig is sufficient) q 9.Site diagram or additional well details:
' •7/.r j �1 ��„� / W You may use the back of Us page to provide additional well site details or well
_ N ) / abandonment details. You ma also attach additional pages if necessary.
CONSTRUCTION 1pim LS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
.9ttach well ewtstructiorlrecord(s)ifavallable.For multiple Injection ornon-wwtersupplywalk
ONLY with the same coitrstr]uctionlabandonmenr,you can submit atejorm. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ilD#: I ! abandonment to the following:
Division of Water Resources,Information Processing Unit,
iD
1617 Mail Service Center,Raleigh,NC 27699-1617
6b:Total well depth:. d
10b.For Infection Wells: In addition to sending the form to the address in 10a
above,also submit-one copy of this form within 30 days of completion of well
Borehole diameter: (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6.d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
loc.For Water Suauly&II iection 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
abandoned.
6f.Inner casing/tubing length(if known);
Ag.Screen length(if known):
\ Revised 2-22-2016
Form GW,30 North Carolina Department of Environmental Quality-Division of Water Resogrces

i
WELL ABANDONMENT REC®" For Internal Use ONLY:
4 �
1.Well Contractor Informatio : WELL ABANDONMENT DETAIYI S
god xc/ 7a.For Geoprobe/DPT or Closed Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well onhis/Irer property) well construction/depth,only 1 OW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
��'C�J ��j i e/s /j�C✓ FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:T/ 7/
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,'County,State,Variance,etc.)iftamwn
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) geesidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Cormnercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation ?,-x je'b IK5
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
El Experimental Technology ❑Subsidence Control
7g.Provide a brief description of-the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) "`'t �I/ / �`lDr�fr �14Li� 3�s'+T D�
4.Date well(s)abandoned:
I
5a.Well location: NOV V 12023
acility/Owner Name Facility IDfl(if applicable) 8.Certillcatio
Physic 1 Address,City
and rp Signature rtfiedi Well Contractor or Well Owner Date
��b By signing this form, 1-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 been provided to the well owner.
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:
You may use the back of this page to provide additional well site details or well
N W
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SiJB TTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same constructionlabandonment,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:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 41� (ft.) 1617 Mail.Ser•vice!Center,Raleigh,NC 27699-1617
10b.For Infection 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:
i
i
6d.Water level below ground surface: (ft.) Division of Water Resources;Underground Injection Control Program,
1636 Mail Service'Center,Raleigh,NC 27699-1636
6e Outer casing length(if known): ({t,) 10c.For WaterSupaly&Infection Wens: 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
6f.Inner casing/tubing length(if known): (ft.)
abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1 ,
1.Well Contractor Informat' n: WELL ABANDONMENT DETAILS
A14M 7a.For GeoprobelDPT or Closed-Lnop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on Iris/her property) well construction/depth,only 1 GW 1 30 is needed. Indicate TOTAL NUMBER of
�(� _ wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water!reroaining in well(s): (gal.)
��� j _
C C�/� �rf �r1 C' FOR WATER SUPPLY WELLS ONLY:
Company Name /
l DD 1 130 7c.Type of disinfectant used: rG>y,kt/�t' azwrL-r_
2.Well Construction Permit#:
List all applicable well construction permits(l.e.UlC,'County,State,Variance,etc.)iflotowh
7d.Amount of disinfectant used: �D
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all'that apply):
❑Agricultural ❑M�unicipal/Public ❑Neat Cement Grout I23'I3entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) C3Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Cormnercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
ElIrrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation /� 1�`f '
❑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) ❑ 1W
❑Geothermal(Heating/Cooling Return) ❑Other Other(explain under 7g)
16
z3
4.Date well(s)abandoned:
5a Well location: .. ,.` r
Facility/O�Nam�a V Facility ID#(ifapplicable) 8.Certification: Erl V J 1 2023
IV
Physical Address,Ci and Zip Si tuned Certified Well ontractorot efl*Oivriei
p°3 Z I ^2� By signing this form, 1-hereby certify that the wells) 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 been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long 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.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Altach well construction record(s)tfavailable.For multiple infection ornon-watersupply wells
ONLY with the same constructionlabandonment,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:
Division of Water Resources,Information Processing Unit,
6b.Total well depot: (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: (in.) above,also submit one copy of iis'form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (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 the
6e.Outer casing length(if known): (ft.) address(es)above;also submit onelacopy of this form within 30 days of completion
of well abandonment to the county health department of the county:where
6f.Inner casing/tubing length(if known): (ft) abandoned. 4
6g.Screen length(if known): (ft.)
Fonn GW-30 Nortlr Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016