6001_Mecklenburg_Harrisburg_MSWLF_WellAbandonment_FID1528491_20210210

WELL ABANDONMENT RECORD
1. Well Contractor Information:
michael estes
Well Contractor Name (or well owner personally abandoning well on his/her property)
4445- b
NC Well Contractor Certification Number
mcc_a_II hrothPr�
Company Namo
2. Well Construction Permit #: 10011752
List all applicable well conshuction permitsT,e. UIC, County, State, Variance, eta,) jjlmown
3. Well use (check well use):
Water Supply Wolf:
❑Agricultural OkMunicipat/Public
❑Geothermal (Heating/Cooling Supply) OResidential Water Supply (single)
OInduslrial/Commereial OResidential Water Supply (shared)
.Non -Water Supply
•tjAquifer Recharge
QAquifer Storage and Recovery
❑Aquifer Test
❑ISxperimental'l'ecbnology
QGeothermal (Closed Loop)
QGroundwater Remediation
❑Salinity Barrier
gStortnwater Drainage
❑Subsidence Control
Q"racer
4, Date wells) abandoned: 1�27�2021
For internal Use ONLY:
7a Tor C.eoprobelDPT or Closed -Loop Geothermal Wi+llshaving we same
well construction/depth, only I GW-30 is needed. Indieate'fOTAL NUMBER of
walls abandoned:
7b. Approximatevolumc of watcrxemaining In well(s): (gal.)
X pR WATER L7vKKLY WELLS ONLX:
7c Type of disinfectantuscd; granular chlorine
7d. Amount of disinfectant used:
7e. Sealing materials used (check aU that apply);
❑ Neat Cement Grout 0 Bentonite Chips or Pellets
❑ Sand Cement Grout
Concrete Grout
O Specialty Grout
Cl Bentonite Slurry
Q Dry Clay
❑ Drill Cuttings
Q Gravel
Q Ol ter (explain tinder 7g)
7f. For each material selected abovq provide amount of materials used:
51 x 501bs bentonite chips
x 150115s qulc re e
7g. Provide a brief description of the abandonment procedure;
II pumptcut
casing,chlorinated,
pour
"I�ln
o
VVq=11
C3HU
CIUUt=U
concref
Sa. Weil location: _................ ....... , ........
maintenance shop
Facility/OwnerNeme
8525 pence rd
Physical Address, City, and Lip
mecklenburg
County
Facility IDN (if applicable)
Parcol Identification No. (PIN)
5b. Latitude and longitude In dcgreestminutes/seconds or decimal degrees:
(ifwell field, one let/long is sutTicient)
35.21654 N-80.69025 W
Atrach well eonsh•uction reear!(s,) (favaila6le, Fornndtiple f>ijection a• non-ivatersupply wells
ONLY with the same constractinn/abandonment you can sub,ntt onejam.
fia. Well. ID#: 1
Gb. Total well depth: 200 (ft,)
Ga Borehole diatncter: 6 (in.)
6d. Water level below ground surface: 25
Ge. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
Gg. Screen length (if Imown). (ft.)
8, Certification:
1/27/2021
Signature of Certified Well Contractor or Well Owner Date
By signi,:g this jnrm, I hereby carte that the well(e) was (were) abandoned it:
accordance with I SA NCAC 02C.OIOU or 2C .0200 Well Construetton Standards
oral that a copy ojthis record has been provided to the well owner.
9. Site diagram or additional well details:
Xou may use the back of this page }o provide additional well site details or well
abandonment details. Xou may also attach additional pages if necesstuy,
SUBMITTAL INSTRUCTIONS
]Oa. For 'All Wes: Submit ibis form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
161.7Mail Service Center, Raleigh, NC 276994617
Injectiott,Welj@: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of w
ell
abatadonnrenttuUre following:
Di
vision of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 276994636
].Oc. For Water Supply &Injection Wells: In addition to sending the form to the
addres(es) above, also submit one copy of this form°within, 30 days of completion
of well. abandonment to the county health deparianent of he county where
abandoned,
Fonu G\V-30 North Carolina Dopartmeat of Environmental Quality - Division of Water Resources Ttevised 2-22-2t716