Mecklenburg_Well Abandonment_20240116

WELL ABANDONMENT i
RECORD or
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1.Well Contractor Information. tt WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-I oop Geothermal Wells having the same
Well Con ctorNames(or well1wner personally abandoning well onitis/herproperty) well construotion/depth,only IGW-30is needed. Indicate TOTAL NUMBER of
'.r �) wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water lemaining in well(s): (gal.)
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j2 �j ,��C� FOR WAT1;R SUPPLY WELLS ONLY:
Company Name 1 r] �
1 7c.'Type of disinfectant used:
2.Weld Construction Permit•#: f
List all applicable well construction pe niis r e(e UIC,'Comity,State,Parlance,etc.)ij/mown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check ul1 that apply:.
❑Agricultural ❑M icipaUPriblic Cl Neat Cement Grout entonite Chips or Pellets
❑Geothermal(Heathrg/CooliHg Supply) d .idential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Ini 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 Rechar a ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑L-xperimental Technology ❑Subsidence Control
7g.Provide brief description of-the abandonment procedure:
❑Geothemal(Closed Loop) OTracer
❑Geothermal(Heating/Coolirig Return) ❑Other(explain under 7g) 14 L "=_= =--
4.Date wells)abandoned: /V ' JAN 1 b 2024
5n Well
location:
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Facili, /OwnerNmne / Facility IDN(if applicable) S.Certification: ,
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Plpsicall Address,City,and Zip , Signature of Cery fled Well Connector oiWell Owner Date
By signing this form,'•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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well,field,one tat/long is sufficient) 9.Site diagram or additional well details:
t/ //. ��# � W You may use the back of this page Ito provide additional well site details or well
N — abandonment details. You may also,attach additional pages if necessary.
CONSTRUCTION DU TAILS OF WE, BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach ia,ell conru•trction recard(s)ijavailable.For multiple ijec6an avron-water supply wells
OrVL1✓tiiRth the some coDnstruction/abandonment,you can submit onejonn• 10a. For All Wells: 'Submit this'form within 30 days of completion of well
6a ,'Well ID#: D abandonment to the following:
Division of Water Resources,Information Processing k1nit,
6b.Total well depth: / d (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
5e Borehole dlanreter: fin.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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6d.Waterlevel below ground surface: �U (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e Outer casting length(if'mown): (ft) 10c,For Water Su &Hnie pply c tlofi Wellra• In addition to sending the fonn to the
addresses)above,also submit one'oopy of this form within 30 days of completion
of well abandonment to the county health department of the county'where
6t:IRmer casingltubing length(if(mown): M.) abandoned.
6g•Screen length(if known):
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Form G W-30 Nortb Carolina Department of Environmental Quality-Division-of Water Resources Revised 2-22-2016
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