Iredell_Well Abandonment_20241115

WELL ABANDONMENT RECORD For Internal Use ONLY:
I �
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Edwin Mullis 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
3518-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water!remaining in well(s): 230.79 (gal.)
Gopher Utility Services, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name $1teri len e
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.)iflmoun 2 cups
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agriculttrral ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑hidustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑hrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 54 bags hole plug
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description off the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer pour and hydrate
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date wewelt(s) 11/6/2024(s)abandoned:
5a.Well location: 11 Z024
Joseph Conde
Facility/Owner Name Facility ID#(if applicable) 8.Certiticatio
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2079 Statesville Hwy, Mooresville, NC 28115 � � r 11/6/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Iredell
By signing this form, I hereby certify that the wells) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C:0100 or 2C.0200 Well Constnuction 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 lat/long is sufficient) 9.Site diagram or additional well details:
35.618756 N 80.825681 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(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Auach hell consFriteiio-n record(s)-iifavdilabid.For mrdtiple injection"or non-watersupply wells
ONLY with the same construction/abandonment,you can submit oneform.
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: 202 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
6 1/8 10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: ,
I
6d.Water level below ground surface:
45 (ft.) Division of Water Resources,lUnderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): N/A (ft.) 10c.For Water Suaaly&Infection-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): (ft.) abandoned.
6g.Screen length(if known): (ft.)
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Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-201 G
li

oyw� - 94
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Alfred Kieslin Jr
9 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
3266—A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
B & K Well Drilling Inc FOR WATER SUPPLY WELLS ONLY:
Company Name 'Chlorin e
7c.Type of disinfectant used:"
2.Well Construction Permit#: �(J - 41pie (
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use): ;i
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public R11q Sat Cement Grout 015entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply). PResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout i, ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry I ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
!❑Aquifer Test ❑Stormwater Drainage 1 n. Lt d
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description'of t e abandonment procedure:
�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) of
4.Date well(s)abandoned:
5a.Well location: 2024
"y
I/ 1
welaL otas
Facility/Own 8.Certification:ame Facility ID#(ifapplicable)
Physical Address,City,and Zip Signature o erti "Well ntractor cll O ate r
4&2?-( 02 q- 5 ''
9 By signing this form, I hereby'certify at the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NC-AC 02C.01 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 lat/long is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may6lso attach additional pages if necessary.
P
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS'
Attach well construction record(s)ifavailable. For multiple injection or non-watersupply wells
ONLY with the same constructionlabandonment,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: 3® (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: I?- (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
I
6e.Outer casing length(if known): (R,) 10c.For Water Suaaly&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
6E Inner casing/tubing length(if known): (ft,) abandoned.
I
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resoure Is Revised 2-22-2016