Mecklenburg_Well Abandonment_ (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
DAMES MORRISON 7a.Numberofwellsbeingabandlned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-[rater supply wells 0N1 Y will? the .same
C -4421 construclion/abandonmem,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of water'remaining in well(s): 13.75 (gal.)
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELL5ONLY:
p
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit#: I
List all applicable well construction pertnits(i.e.County,State,Variance,etc.)ijknown 7d.Amount of disinfectant used:— MAY
® 2o22
3.Well use(check well use): ' `.�G r r,-- tg Uflb
Water Supply Well: 7e.Sealing materials used(check all that apply): ^ �'Qlc�,pf
❑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: El Bentonite Slurry ❑ Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
El Aquifer Recharge ❑Groundwater Remediation 34.5 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#(ifapplicable) 8•Certification:
6210 WILKINSON BLVD CHARLOTTE 28214 "'�1'�i'""'"` 03/30/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
MECKELNBURG By signing this form, 1 hereby certify that the tvell(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 ivell owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 14' 08.78" N 800 56' 44.66" 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(s)if available. For multiple it jeclion or non-water supply
wells ONLY ivilh the some construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#:
DPE-4 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 53.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter 4 0 (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: 32.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Sunaly&Iniection 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
Gt:Inner casing/tubing length(if known): (ft.)
where abandoned.
6g.Screen length(if known): (ft.)
Fonn GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013