Mecklenburg_Well Abandonment_20231122

WE'LL
LORD
.� For Internal Use ONLY: 3c
I.Well Contractor Informatiow. WELL ABA7 DONWN'1'D�TAILS
1U1�ch0. (. m
7a.For GeoprobeJllPT or Cloyed-Loop Geothermal Wells having the saute _
well Contractor Name(or well paver personally abandoning well on ws/herproperty) well consUvction/depth,only 1 GW 30 is needed, Indicate TOTAL,NUMBER of
2-,q,7?J_ n wells abandoned:
xe.Well Contractor Certification Num1mr 7b.Approuimote.volume of water remaining is well(s): YL�,e__
- -�`raK Ci w 1 a-1,0 FOR WA RSUPPLY WELLS any.
Compmy.Name r
lc.Type ofdhinfeetaut used•i i T
x.Well Construction Permit#:_ I Ott 1 2-
Lbt allapplicable uva Fonstruclian permils(1.e.Ult,Cari»!y,Stale,Variance,sic.)Jjknolvn
7d.Amount tofdistnfectaat used:__ G to
Ap �T
3.Well useloeck_-cell use): .
Water S.apply Wellz 7e Sealing materials used(theeklaU that apply):
CiA gricultural t imunicipaUpublic O Neat cement Grout Ll Bentonitc Chips or Pellets
06eothermal(lieating/Co0lipg Supply) 926sidential Water Supply(single). 0 Saad Cement Grout tl.Dry Clay.
0hidasidWComtnere al DResidentialVater Supply(shared) W concteto Grout 13 Drill Catt nip
Oirn anon .13 SpecialtyGrout ❑Gravel
1... Non Water Supply Well: .p Bentoaite Slurry _
ClMonttoring �--tlitecovery — -- - --- --�9ilter(implainnWer_7g)
Wicedon Well: 711 For each material selected above,provide amount of materinls used:
OAquifer Rechargo (30rdundwatee Rvatediation P� N a S
t7 Aquifer Storage and Recovery' OSalituty l3ntxier _ sJ r„�,__
C1AgutfecTest OStormwaterDrami ,
t7Experintbtuai Technology L7Subsidence Control 7g,Provide a brief description of the ag8ndentuentproce lure:-
QGcothermal(Closed Loop) 13Tracer ff `
tifieptheriaal([•leathig/CooHn Retum) C]Olher(ex lain under 7g): ��.l lJt�i L C�.B k c I
..4.Date Ncu(s)ttbeddoned:ter„. � N n v 2 ��
Sa.Well location•
e cc �Qpi (,vtertylt
Facility/Uninerpe Q�J+iil,a t+ I,LC Taci*H)o(if appticabte) 8.Certificatio
r.Ne n:
-t: , y3 g l�l�yHe/�c��h�r`d-���U•,_C', �2 I--� I � 1`/�'Z3
Kpical"Addr=LCity,and zip
Signature of Outificd Well Contractgi Orwell Owm Date
By.stgning 71ds fprnr,l hereby Vert that the lvell(s)was(were)abandoned in
4M1 County ParcelIdeatiticationNo.(PIN) apcgrdan7 a with ISANCAC 62C.DI00'6r2C A200 lPe1l Consiructinit Standards,
� 4 5b.Latitude and longitude 1n degreeslminotes/seeonds or decimal degrees: and that° yo
rhts record has been provided to the well owner.
(if wcU field,one IaWng is sufficient)
9.Site diagrem-or additional well details:
W .You tray use the back of this page to provide additional-well site details or well
�""`" —"'N"`"""' abandotutieaElletails. You.may.also attach additiotutl pages.if necessary.
COPISTRUCfIONDE'f�1I40F WIFLI(^+�_BEiNGMD
Emma" U dN AttncweltconsLuclto»retard(s�ftJmailable.Aormirltlple/i{jecllo�iornon.watersrJyµelis
O1VLYwith tkesvm¢carstructlwc�abandonmerit,;ott can submit oneJbrm.
IOa,Rgr Ail Wills: Submit this tbrm within 30 dpyswof completion of v�eil
60.Wen Dm#: N abandotment to the following:
(� Division of Water-Resources,Information Processing Unit,
6b.Total well depth. 2 O ( )' 1617 MailStrvlce Center,RpleigdrNC. 7649-1617,
i
lob.Fur blectlon Welke Jn addition to sending:the form to the.addtess.ip 10a
6c.Borehole diameter:_ pa) 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: N ( ) Division of Water Resonrcest Underground;Injection Control Program,
16M man serwce�Ceater,Relelgh;NC17699.1636
6e.Outer cx+sing length( known): � (D,) loc.Tg f titer 5unnk&Inlect(on Wells; in addition to sending tine form.to the
addresses)above;also submit, copy of this fomr wtthm:30 days of completion
of well abandonment to the county health,departiment of the county Where
Of:Inner casing/tubing length(if kmown); �(iti,) abandoned:
69:Screen length(trlmown):
r..a.,,roman .. _ ..