Mecklenburg_Well Abandonment_20240403 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Con Info tpation: WELL ABANDONMENT DETAILS
JJ b/ tc �l 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(orwell owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certifi Number 7b.Approximate volume of water remaining in well(s): (gal.)
i
�t y FOR WATER SUPPLY WELLS ONLY:Company Name 7c.Type of disinfectant used: 7—
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2.Well Construction Permit#: /62 / -2:2 / J
List all applicable well construction permits(i.e.UIC,County,State, ariance,etc.)ifknown
7d.Amount of disinfectant used: r
3.Well use(check well use)::
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Munici al/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating(Cooling Supply) esidential Water Supply(single) ❑ Said Cement Grout ❑Dry Clay
❑lndustnal/Commercial ❑Residential Water Supply(shared) Concrete Grout ❑Drill Cuttings
01rri tion ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentoriite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7£For each material selected above,provide amount of materials used:
❑Aqu fifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedure:
�,
❑Geothermal(Heating(Cooling Return El Other(explain under 7 ) T( U�r�l CJ / ! �O Iq C l'- r
4.Date well(s)abandoned:- 7 6/(
5a.We cation:
end ✓��� f
Facility/Owns Facility IDR(ifapplicable) S.Certification•
Physical Address,City,and Zip Signature o Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record hai
(ifwell field,one Wong 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 WELL(&BEING ABANDONED SUBMITTAL LYSTRUCl'IONS
Attach well construction record(s)&vailable.Formuluple injection or non-watersupply wells
ONLY with the some construction/abandonment,you can submit one form.
/ 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: _ / V colt e abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: -3 0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter. (io) 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: / A) Division of Water Resources,Underground Injection Control Program,
ll 1636 Mail Service Center,Raleigh,NC 27699-1636
V 6e.Outer casing length(if known): (g,) 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
6£Inner casing/tubing length(if known): `9 M (fL) abandoned.
6g.Screen length(if known): O (fy) <r. '_r "'; +1� 1•-w:,
APR 0 2024
Form GW-30 North Carolina Department of Environmental Quality-Division of Watgr Resources Revised 2-22-2016
1nx- �.,: n._