Mecklenburg_Well Abandonment_ (6)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple it jection or non-water supply wells ONLY with [lie saute
C - 4421
constructiau/abandonaent,you can submit,one form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS ONLY: c ?�
Company Name 7c.Type of disinfectant used: MAY
2.Well Construction Permit#: MAY 3 0 2022
List all applicable ire/l construction permits(i.e.County,State,Variance,etc.)ifknoum 7d.Amount of disinfectant used:
3.Well use(check well use):
Q%�ti7C�
Water Supply Well: 7e.Sealing materials used(check all 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: 0 Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring El Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 19.0 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#(ifapplicable) $•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 fount, 1 hereby certify that the well(s)was (1vere) abandoned in
County Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided io the ivell owner.
Sb.Latitude and longitude indegrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 14' 09.86" N 800 56' 44.82" You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(v)if available. For i n lliple b jection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one fora. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: AS-20 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 117.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
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 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&Iniection Wells: In addition to sending the form to
Ge.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
611 Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013