Cabarrus_Well Abandonment_20220701

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1.Well�44
tractor Information: WELL ABANDONMENT DETAILS
`�y b(L 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contracto amp(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30' needed. Indicate TOTAL NUMBER of
/ (5 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):_ •S (gal.)
Morgan Well & P u mp,r I N C FOR WATER SUPPLY WELLS ONLY:
Company Name granulated chlorine
7c.Type of disinfectant used: g
2.Well Construction Permit 4:
List all applicable well construction permits(i.e.VIC,County,State,Yariance,etc.)if lwomr 6 V
. 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that appl ):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout OZgentcmite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑ridustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Hgation ❑ Specialty Grout ❑ Cnavel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each maat7erW selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation �/ �(r ys t'6
❑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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 14 eR,(e J
-en t��r is
4.Date welI(s)abandoned: i 191;D.
Sa.Well location: � I�II � .� 2022
Fac O e II JJ-- Facility'IDf#(ifaJp�plicalble) 8.Certification: l i .-,,�eD1?iDC;t�£4 uD�
S� , f�v\ —"IiJr`""' ICJ �4(/+c ra" ;1 6'Z'Z
Phdress,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Ms,rr')
By signing this farm, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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 we me la o sufficient) 9.Site diagram or additional well details:
J[ �� U You may use the back of this page to provide additional well site details or well
N l 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)ifavailable or multiple injection or non-water supp]y wells
ONLY with the some construction/a nment,you can submit one farm.
10a. For All'WeIls: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
(') Division of Water Resources,Information Processing Unit,
6b.Total well depth: `-' (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
) Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft
/ 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft) 10c.For Water Supply&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 where
6f.Inner casing/tubing length(if known): (ft.) abandoned
6g.Screen length(if known): (fh)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016