Mecklenburg_Well Abandonment_ (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAM ES MORRISON 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-hater supply wells ONLY with the satire
construction/abandonment,you can submit one form.
C -4421 5.5
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS ONLY: r�
Company Name 7c.Type of disinfectant used: 6
2.Well Construction Permit#: 14AY 3 0 2p
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: l'
3.Well use(check well use): r:.J3,, i UM
Water Supply Well: 7e.Sealing materials used(check:ill that apply):
❑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: IZI 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 10.0 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 v �"" ""`"` 03/30/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
MECKELNBURG By signing this fain, 1 hereby certify that the ivell(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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 hat/long is sufficient) 9.Site diagram or additional well details:
350 14' 09.17" N 800 56' 44.74" 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
Attach well construction record(s)if available. For multiple itjection or non-water supply
wells ONLY with the satire construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#: AS-9 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 62.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
Gc.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 37.0 (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Ge.Outer casing length(if known): (ft.) 10c.For Water Sunnly&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
61:Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form G W-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013