Mecklenburg_Well Abandonment_20220708 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Informjm on: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Nime(or well owne ally abandoning well on his/her property) well construction/depth,only 1 OW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC t C era r Certification umber 7b.Approximate volume of water remaining in well(s): (gal.)
JG( ��5 r FOR WATER SUPPLY WELLS ONLY:
Company Name
1 l ll 7c.Type of disinfectant used:_
2.Well Construction Permit#:
List all applicable well construction permits(i.e.U/C,Couno%State, Variance,etc.)tfknown I. O�
7d.Amount of disinfectant used: b
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply•'
❑Agricultural WoMun' ipal/Public ❑ Neat Cement Grout "�tonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ntial Water Supply(single) ❑ Sand Cement Grout ❑ Dry.Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explainlunder 7g)
❑Monitoring ❑Recovery
Injection Well: 7t:For each material selected above,provide am'�ouuntt of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
P�u.
.❑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
A❑Geothermal(Heatin Cooling Return) ❑Other(explain under 7 ) ,�//�
well(s) :to sub � !.
.abandoned -`• -°�' '"`"4.Date well
5a.Well location:
dePl13PW121�II
Facility/O;v eJN me G, FagilityID#(ifapplicable) 8.Certitl ation:
Physi I Address, i ,and Zip e, Sign ure of Certified Well adtauor or Well Owner D
By signing this form, 1 hereby cert(fy that!the well(S) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C:0100 or 3C.0200 Well Construction Standards
and that a copy of this record has been provked to the well owner.
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:
You may use the back of this page to provide additional well site details or well
i N W abandonment details. You may also attach additional pages if necessary,
CONSTRUCTION,DETAILS OF WELLS)BEING ABANDONED
Attach well canstructionrecord(s)ifavailable.For multiple Injection or nat-water supply wells, SUBMITTAL INSTRUCTIONS
ONLY with the same co%structlon/abandonment,you can submit one farm. 10a. For All Wells: Submit this form within 30.days of completion of well
6a:Well 1D#: I abandonment to the following:
Division of Water Resources,Information Processing Unit,
6L Total well depth: ({t,) 1617 Mail Service Center,R i aleigh,NC 27699-1617 i
10b.For Infection 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: I
i
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6t.Outer casing length(if known): ({t,) 10c.For Water Sunoly&Infection Wells:)it,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): (ft.) I
North
Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-T016
:Form GW,30 P

RD For
WELL ABANDONMENT RECO .Y:
1.Well Contractor Information: s WELL ABANDONMENT DETAILS
7a.For GeoprobelDPT or Cloned-Loop CreotheMmal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is nb ded. Indicate TOTAL NUMBBR of
wells abandoned:
7b.A pproximate volume.of water remaining In well($): gal.)
NC 1 optrecttor erti an ,on ber .
lFOR WATER SUPPLY WELLS OIyL�
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well ewwtrpetion permits Q.e.WC,Couap�State,Variance,etc.)10nomi 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout P<entonite Chips or Pellets
❑Geothermal(Heating/Coo_ling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ! ❑Dry Clay
❑ trial/Commercial ❑Residential Water Supply(shared) O Concrete Grout ❑Drill Cuttings'
ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑.Bentonite Slurty 4 ❑Other(explaip under 7g)
❑lylonitoring ❑Recovery
Ytijection Well: 7E For each n aterial selected ve, vide amoant.of material used;,
❑Aquifer Recharge ❑Groundwater Remediation `
.❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Teat ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control .
7g.Pro e a brief descr d oI' a b>♦ndonm t procedure.
❑Geothermal(Closed L60R) ❑Tracer l
❑Geothermal tin Coolin 'Retum []Other(explain under 7g)
41
LV
4.Date well(s}abandoned:
52.Well location:
JUL-,
Faoility10,,hw Nam /j,�//(J�/ Facility M#(if applicable) 8.Cer cation: i
, -/�+••+ / tom,/ /r,�/�1 M 2
Physic Address,City,and Zip 3Igoatute of fiad Vall SAW,or e 1 of Date
eG By signing this form,I hereby eertlfy that the well(s) Has(mere abandoned in
County Parcel Identification No,(PIN) accordance with 15A NCAC 02C,0100 or'i2C.0200 Well Construction Standard?
and that a copy of this record has been prodded to the wellowner.
Sb:Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if well field,one lat/lodg is sufficient) 9.Site diagram or additional well details.,
50 IT S r N �5 Sq _W You may use the beck of this page to proyida aaditional well site.deWls:!or well
' - / abandonment details. You may also attach'!ttddltional pages i('necessary.
TR I ET I O L B D SUBMITTAL INSTRUCTIONS
Attaoh well consmwdo record($)(favallable.Formulttphr hilection or non-waterewply walls
ONLY'with the same c tnrctlon/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 3,0 day8 of completion of wel�
6m Well tD#: V abandonment to the tbllowing:
Division of Water Resources,Information Processing Unit,
66:Total well depth:. (ft.) 1617 Mail Service Center,Raleigh;NC:276"-1617,. i
10b..For Infection Weila: In addition tolsending.the form to the address. 100
Kc:Biurehole diameter: (in.) above,also submit-one copy of this formwithin 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 Man Service Center,Raleigh,NC 27099-1636
casing length(if known) (ft.) 10c.For Water Suuuly&Infection l'Ye_IM In addltion to sending the form to the
6e.Outer
address(es)above,also submit one copy ofithis form Within 30 days of completop
of well abandonment to the county health department of the ooanty'wh
�� abandoned.'
6f.Inner casing/tubing length(if known):J' (ft.)
6g.Screen length.of known):
' Revised 2.22-2016
Furm OW,30 North Carolina Department of Environmental Quality-Division of Water Resourbes

. -19 j
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor 14ame(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: � 4
NC we 1 Contractor Certification Number 7b.Approximate volume of water remaining in wells): _(gal.)
Ql/ ,jr�S. 11/� FOR WATER SUPPLY WELLS ONLYCompany Name
7c.Type of disinfectant used:_
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc)lfknown 1 Wit/
7d.Amount of disinfectant used: "��✓✓
3..Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ S d Cement Grout ❑Dry Clay
d strial/Commercial ❑Residential Water Supply(shared) ncrete Grout ! ❑Drill Cuttings
ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
injection Well: 7f.For each material selected above,provide a ount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1 d 5 Q <x
.❑Aquifer Storage and Recovery ❑Salinity Barrier ---
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the aba�tdonment procedure:
❑Geothermal(Closed Loop) ❑Tracer j- 1I.
❑Geothermal(Heating/Cooling Return)
) ❑Other(explain under 7 ) �/ / �(b l�P� 1�n
4.Date well(s)abandoned:
5a.Well location:
Facility/Owner Name Facility ID#(if applicable) 8.Cart cation:
Physical Address,City,and Zip ignature of Ce ed Well Contractor or Well bcaner Date
By signing this form, I hereby certify that!the well ryas (here)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.
SIr'.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wellad,one la is sufficient t Q f 9.Site diagram or additional well details:f
��) W n 6 Q, / You may use the back of this page to provide additional well site details or well
�( � `u� abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructio record(s)ifavailable.For multiple Injection or non-water supply wells
ONLY with the same ccinstnnction/abandonment,you can submit one form.
10a. For All Wells: Submit this form vlithin 30 days of completion of well
6a.Well ID#: abandonment to the following;
Division of Water Resources,Information Processing Unit,
fib:Total well depth: 1617 Mail Service Center,Raleigh,NC 276994617
I n 10b.For Iniection Wells: In addition to sding the,form to the address'in 10a
6c:Borehole diameter: (in.) above, also submit one copy of this form*ithin 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
fie.Outer casing length(if known): /yd 1 (ft.) 10c.For Water Sunoly&Iniection Wells:;In addition to sending the form t�the
address(es)above,also submit one copy of Ois form Within 30 days.of comp, tipn I
of well abandonment to the county heal(h department of the county where I
abandoned.
6f.Inner casing/tubing length(if known): /t/ (ft.)
I
6g.Screen length.(if known):
I
Revised 2-22-2016
:Form GW-30
North Carolina Department of Environmental Quality-Division of Water Resources
1