Mecklenburg_Well Abandonment_20240403 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Con ranfnrmation: /) WELL ABANDONMENT DETAILStJ ( t `<' /r/G�Z) 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:
n
NC Well Conuact(.f�ertifi/cation Number 7b.Approximate volume of water remaining in well(s): (gal.)
Gr r FOR WATER SUPPLY WELLS ONL9Y::� / l Company Name t� 7c.Type of disinfectant used: // / `
2.Well Construction Permit#: ' t 6 0/�(/ / &') '
List all applicable well construction permits(i.e.UIC,Cotmry,State,Variance,eta)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use)::
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mtmicipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) DR<diential Water Supply(single) ❑Sand('ement Grout El Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) !_aConcrete Grout ❑ Drill Cuttings
DIrrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite 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 OSubsidence Control
7g.Provide a brief description of the abandonment pr gdure:
❑Geothermal(Closed Loop) ❑Tracer r 1
❑Geothermal(Heating/Cooling Rettun ❑Other(explain under 7 ) rD //1 4'd �n
4.Date well(s)abandoned:
5a.Well ovation:
41 �d
Facility/Owner Name Facility ID#(' applicable) S.Certification: J
Physical A City,and Zip. Signature of rtified Well Contractor or Well Owner Date
JI
By signing this form, 1 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
5b.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 Iavlong 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 WELLISI BEING ABANDONED SUBMTTTAL INSTRUCTIONS
Attach wellconstructionrecord(s)ifavadable.Formultiple injection ornon-watersupply 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
A/6a Well ID#: C� n abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: ©� (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in I Oa
6c.Borehole diameter: (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: J / (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (R,) 10c.For Water Sunnly&Iniec+tion 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-jlealtk-department of the county where
6£Inner casing/tubing length(if known): ^2 (ft.) abandoned. i, s'-, -"`( : f t
E°�:.e�.✓ L�1. V,
U pp &"
6g.Screen length(if known): Al
APR V O
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Re�glyyl a'-DC Revised 2-22-2016