Mecklenburg_Well Abandonment_20240403

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Con t Information:
'i` WELL ABANDONMENT DETAILS
a (t R 1 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 I GW-30 is needed. Indicate TOTAL NUMBER of
` wells abandoned:
NC Well Co for �ettification Number 7b.Approximate volume of water remaining in well(s): (gal.)
1
G` FOR WATER SUPPLY WELLS ONLY:
Company ame I6/�/)Y
D �1`7 g �VC,
Type of disinfectant used: f7'
2.Well Construction Permit#:
List all applicable well construction pe (i.e.U1C.County,State.Variance,ere.)J ow
n ( b 7d.Amount of disinfectant used:
3.Well use(check well use)::
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Muni • ahPublic ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating(Cooling Supply) esidential Water Supply(single) ❑ San ent Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) - oncrete Grout ❑ Drill Cuttings
Oh-rigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentorite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7£For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer Tdrzp7g.Provide�� tion of the abandonment ocedure:
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❑Geothermal(Heating/Cooling Return, ❑Other(explain under 7 ) �—/ s el C/-&
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4.Date well(s)abandoned: D
52.Well ati
Facfl ty/Owner Name V Facility ID#(if applicable) 8.Certificati
15L - 6 ��y
Physical Address,City,an�dZ}p Si ofCettified Well Contractor;or Well Owner Date
Cotmty Parcel Identification No.(PIN) By signing this form, I hereby certify that the well(s) was (were)abandoned in
accordance with 15A 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 well owner.}
(ifwell field one lallong 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 WELLS)BEING ABANDONED SUBMTTTAL INSTRUCTIONS
Attach well construction records)ffavailable.Formultiple injection ornon-watersupply wells
ONLY with the same consirl.on/ahandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well W#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
�i 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter. U (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 0/N-L (ft,) Division of Water Resources',Underground Injection Control Program,
1636 Mail Service;Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):_11 (t A) 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
6L Inner casing/tubing length(if known): A) abandoned. _
6g.Screen length(if known): i/?
(ft.) APR 0 V 2024
Form GW-30 North Carolina Department of Environmental Quality-Division of WatetEff4"b»
Revised 2-22-2016
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