Iredell_Well Abandonment_20220701

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
/�0 Ph <ZWR�el' 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor a(or well owner personally abandoning well on his/her property) well constraction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
�5/a
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
Morgan Well & Pump, I N C FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: granulated chlorine
2.Well Construction Permit#:
List all applicable well construction permits C.e. UIC,County,State,Variance,etc.)ifbrown
7d.Amount of disinfectant used: '3 02
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that ap'pll
❑Agricultural . ❑ cipal/Public ❑Neat Cement Grout Lntonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ❑ Sand Cement Grout ❑Diy Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑hligation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: . ❑ Bentonite Slurry ❑ Other(explain under 7g)
[]Monitoring ❑Recovery
Injection Well: 7f.For each material selected ab tee,pr-gvide amount of materials used:
❑A uifer Recharge ❑Groundwater Remediation ., a
q g
❑A uifer Storage and Recovery El Barrier 00�b5d--
4 g rl' h' JUL❑Aquifer Test- ❑Stormwater Drainage J J 0 2022
❑Experimental Technology El Subsidence Control--
7g.Provide a brief descriptio Pthp°abaild'ditmn.t�rIeLq
❑Geothenmal(Closed Loop) ❑Tracer , ;;Q;>;( y
❑Geothermal(Heating/Cooling Return) Other(explain under 7g) 4a<< 2' 5 ArON\ ( 'C� I ('uL Ca5I n aj
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4.Date well(s)abandoned: 7 i�� �4_
Ji�
5a.Well location:
Facilr�Name Facility ID#(if applicable) 8.Certifica'
/a5 7/-�Ypql S(-a&syjk � /C �9112—
Physical
Address,City,and Zip Si e Certified We leeb
for or Well Owner Date
By zgrriztg this fo m, I certifythat the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) ccordance with 15 NC
O2C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.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:
86 1 d_ N SQ 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)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment you can submit one form.
10a. For All Wells: 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: '
6d.Water level below ground surface: (ft.) Division of Water Resources,;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection 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
I
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised,2- -2016