Mecklenburg_Well Abandonment_20231122 (12)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GWi 30 is needed. Indicate TOTAL NUMBER of
N C-4229B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <3 (gal.)
EnviroCheck of Vat Inc FOR WATER SUPPLY WELLS ONLY:
Company Name lc.Type of disinfectant used:
2.Well Construction Permit#: 50000480
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflmown
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 C 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
DIrrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation bentonite, 50 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage grout, approx 200 Ibs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer grouted to surface using bentonite/grout.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
removed manhole cover and pad
4.Date well(s)abandoned: 11/20/2023
Sa.Well location: 4 - -
Davey Tree 9705 �
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: ^
6039 McDaniel Lane, Charlotte, NC 28213
�..._... '7
a = 11/20/2023
Physical Address,City,and Zip 7y"s'g.—ning
of Certified Well Contra or Well Owner Date
Mecklenburg 04902204 this fot7n, I hereby certify that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the ivell owner.
(ifwell field,one]at/long is sufficient) 9.Site diagram or additional well details:
33.35221 N 80.69234 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 WELLiSI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attachwellconstructionrecords)ifavailable.rormultiple injection ornon-watersupplywells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-10A abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (ft.) 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (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: 31.90 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Ccnter,Raleigh,NC 276994636
40 10c.For Water Supply&Iniecti I n 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): unk (ft) abandoned.
6g.Screen length(if known): 15 (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016