Mecklenburg_Well Abandonment_20220530

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
1
ES MORRISON JAM 7a.Number of wells being abandoned.
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-haler supply hells ONLY +rith the sane
constructiotdabandonment,you can submit:one form.
C - 4421
5'S
NC Well Contractor Certification Number. 7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS ONLY: ICompany Name 7c.Type of disinfectant used: M r s .+
2.Well Construction Permit#: MAY +l J O �n��
List all applicable well construction permits ri.e.County,State,Variance,etc.)if-known known 7d.Amount of disinfectant used: `/
3.Well use(check well use): Ff1QCiFli on E:55-..R(g Unh
Water Supply Well: 7e.Sealing materials used(check all that apply):EWN,a/BOG
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 10.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 03/18/22
5a.Well location:
THE PARKING SPOT
Facility/Owner Name Facility iD#(if applicable) 8•Certification:
6210 WILKINSON BLVD CHARLOTTE 28214 `°�"`"` 03/30/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
MECKELNBURG By signing this form, I hereby certify that the ivell(s) was (were) abandoned in
County Parcel identification No.(PIN) accordance with ISA NCAC 02C.0100 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 14' 08.64" 800 56' 44.00" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-+rater supply
wells ONLY with file sane construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: AS-4 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 65.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: 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 well
6e.Borehole diameter: 2'0 (in.) abandonment to the following:
37.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Sunoly& Infection Wells: in addition to sending the form to
6e.Outer casing length(if known): (ft.) 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 abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
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Form G W-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013