Cabarrus_Well Abandonment_20240116 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Req
Contractor Information: WELL ABANDONMENT DETAIII.S
t i V/XJ 7a.For Geoprobe/DPT or Closed-LI op Geothermal Wells having the same
Well Contractor Name(or well wner personally abandoning well on hisllier property) well construction/depth,only 1 GW-30 is needed. Indicate TOTALNUMBER of
1���� wells abandoned: I
0
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): O (gal.)
1 1 1 r`l • FOR WATER SUPPLY WELLS ONLY:
Company Name
l 1 �- n '���� 'nC)�„� 7c.Type of disinfectant used:
2.Well Construction Permit#._ j1-�+ +� t 1 � ;
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknoxnt f ® 7
7d.Amount of disinfectant used: ( Ci
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Muuicipal/Public ❑Neat Cement Gr ^+4�„r.r 4Q,6entonite Chips or Pellets
xx??
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ;7h17L3ry, lay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout J/"N 0 Dn 1 Cuttings
❑hit ation ElSpecialty Grout LOZQ❑(}ravel
Non-Water Supply Well: ❑Bentonite ❑ Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: 7f.Fo each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
i
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ::
7g.Provide a brief description of the aban nme t p ocedure:
❑Geothermal(Closed Loop) ❑Tracer �/y /�Q
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) V� 1 I `'t � UQ `C-i Uk'
4.Date well(s)abandoned: a•'` 9
�L
5a.Well location:
cnbd a SY`r� N1
Facility/Owner Name Facility ID#(if applicable) S.Certification:
5 a C s n ' N� - -z�23
Physical Address,City,and Zip gob I Si ertified Well Contractor or a wner Date
,C(��JG1KYuScenu
By signing this form,I hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15,4 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: I.
(if well field,
one llaat/long is sufficient) 9.Site diagram or additional well details:
•"l ` "��8 N ��,�� �u—lq 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.
i
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple b jection or non-water supply wells
ONLY with the same construction✓abandonment,you can submit one form.
L l 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: L/Vabandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: l (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I
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10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 41 A— (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: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Y I (ft.) 10c.For Water Supply&Injection 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
6f.Inner casing/tubing length(if known): AM (ft.) abandoned.
6g.Screen length(if known): !V (ft.)
d
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL AIBAINVV1V1VIE •1' 1. EUO" M IFor Internal Use ONLY:
1.Well ,Contractor Ifn�formation: / WELL ABANDONMENT DETAILS
I-J"C�/L- iLZC )Q f'e✓' 7a.For Geoprobe/DPT or Closed-Lo I p Geothermal Wells having the same
Well ContractorName(or well oRzner personally abandoning well onhis/her property) well constr-uction/depth,only 1GW-30!isneeded. Indicate TOTAL NUMBER of
G�5/Q V c wells abandoned:C.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
Morgan Well & P u rn p t r I N C FOR WATER SUPPLY WELLS ONLY:
Company Name ;, ranulated chlorine
7c.Type of disinfectant used: granulated
2.Well Construction Permit#:
List all applicable well construction permits(t.e.UIC,'County,State,Variance,etc.)iflonwn
• 7d.Amount of disinfectant used: �oZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural __❑Municipal/Public ❑Neat Cement Grout C"Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) UZesidential Water Supply(single) ❑ Sand Cement fEauf" ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply shared� ❑ Concrete Grout _o iz rill Cuttings
❑Irrigation ❑ Specialty Grout JA N "b travel
Non-Water Supply Well: ❑Bentonite Slurry (explain a❑ Other ex lain under 7Q)
ElMonitoring ❑Recovery I'
Injection Well: 7f.For each materialaeJeecte �bo 9e perpvide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1-7 bggS
❑Aquifer Storage and Recovery El Salinity Barrier❑Aquifer Test ❑Stonnwater Drainage ISO
Jd 16$
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ff��
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 1)t'/�o✓'�� ���s �r�M lv0_//�, r A ND
4.Date weIl(s)abandoned: L
5a.Well location: C&Lltrea� IJD
SErab,ft f 'Aa Fh Red as QFe
Facility4vnerName Facility ID#(if applicable) 8.Certifica' n: i
/9al
Physical Address,City,and Zip a e of Certified C acto or Well Owner Date
C4 6 4 r�y s By signing this form, I t y certify,,that the wells) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 154 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:
N D*Q, / W You may use the back of this page to provide additional well site details or well
O `7 abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavoilable.For multiple injection or non-water supply wells
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#: ,/ abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: GQ (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
' 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: t
P
6d.Water level below ground surface: OZ OG (ft.) Division of Water Resources,Underground Injection_Control Program,
1636 Mail Service Centr,�Raleigh,NC 27699-1636
6e.Outer casing length(if known): x (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
6f.Inner casing/tubing length(if known): X (ft.) abandoned
6g.Screen length(if known): X (ft.)
• P i '
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources �, Revised 2-22-2016

I
a STAt$
�lv NMTNT RECORD
� . � ..ELL'asANnQ - - —
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0. North Carolina Department of l3nviroi mcnt and Natural Resources-Division of W i er Quality
'eR WELL CONTRACTOR CERTIFICATION# i'l L L'J L 7 y 1 C
1,WELL CONTRACTOR: b. WELL DETAILS:
a.Totai.Depth—$ Diameter._in.
Well Contractor(individual)Name b.Water Level(Below Measuring Paint): _tt
D HOC Ln W L(I I�T j i)i Measuring point is __It above land surface.
We11 Contractor Company Name '
14v 4D 5 he-r r i t(s FO nd- Ed
6. CASING: ` Length Diameter
Street Address ft. in.
l S� vie, d )4 7 a.Casing Depth(if known):
I�YI.t v ft. �_—in.
1. State Zip Code b.Casing Removed: _
City or-Town
1 tl Ll 1 )o") p DISINFECTION:• t
Area code Ptipne number
(Amounto*65%75%calaum hypochlorite used)
2.WELL.INFORMATION: 1 r
S. SEALING MATERIAL:
SITE WELL ID# (if applicable) Naat Cement Rand Cement
� '
STATE WELL PERMIT# (if applicable) 7G23 �D I Cement 1,. Cement lb,
CH w W Water gal. Water oat.
COUNTY WELL PERMIT #(if applicable)
t3entonite �; T.,
OWQ or OTHER PERMIT#(if applicable} Bentonite lb.
WELL USE(Check applicable use)D Monitoring D Residential Type:0 Slurry- Pellets J.Q f V
i7 Municipal/Public B Industrisitcommerclal D Agricultural Water 9a►• lta$�-- G 2024
0 Recovery G Injection ❑ Irrigation. Other (�•, 4' ���;a
0Other(list use) - - —- Type material �� -
Amount
3.WELL LOCATION: G
COUNTY NkhA- "t15 .QUADRANGLE NAME
C j 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
NEAREST TOWN: 6 hGD
(StreetlRoad Name,Number,Communliy,Subdivision,Lot No.,Parcel,ZIP Code}
TOPOGRAPHC BAND SETTING:
n-Slope 10 Valley 0 Flat 0 Ridge`�'3 Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw A detailed sketch of theeil on the hack of this
,) `� form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE =Z�' � D'ul5 OR 3X.XX)OOci11 fn theweit,gravel interval,intervals of casing perforations,and depths and
`1�J• LI 1 i►j OMS OR 7KIXXxXXX74D types of fill materialsued'
LONGITUDE.�__� 4 y "_ ✓J
Latitudellongittilb,source: 03PS Clfapographic map 11. DATE WELL ABANDONED
(location of well must be shown on a USGS t0p0 map andattached#a
this form if not using GPS) : I DO HEREBY CERTIFY THAT THIS WELL WAS A13ANDONED IN ACCORDANCE
WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
4a.FACILITY-The name ofthe business where thewell is located-Complete 4a: : THIS RECORD HAS EN PBrVII TOTHE WELL OWNER.
(If a residential well.skip.4a;complete 4b,well owner infomation.only.) i'
/2�1Z
FACILITY ID# (if applicable) tY► Y L �� tS SIGMA RE F CERTI IED 1 `CONTRACT R DATE
NAME OF FACILITY P
STREET ADDRESSr� QV i tls a n 11 a% I
Cvb1CDY'LL nL SIGNATURE OF PRIVATE WELL OWNERABANDONING THE WELL DATE
City of Town State Zip Code (The private wail owner must be an individual%time sr ona1ijpbandorts hlslher residential well
in >vdh 15ANCAC 2C@@.Q713,) r
4b.CONTACT PERSONMELL OWNER: VLVL P >n
NAME *RINTEONAMEOFP SONABANDONINGT WELL
I '
STREET ADDRESS
Subintt a copy to the owner and the orjgjllW to;Division,of(IUater QU 11t.y-Information Processing; Form 0-30
1617 MaiFSetvice Center;Raleigh,:NC 276994617,°Phone:.(919).807-G300.-