Mecklenburg_Well Abandonment_20220726

WELL"ANDON MEN T RECO ll For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONbIENT DETAILS
ko-¢-..l 7a.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,onlytI OW-30 is needed. Indicate TOTAL NUMBER of
2413 wells abandoned: /
NC Well Contractor Certification Number 7b.Approximate volume ofwater remaining in well(s): 1 ® (gal.)
r`Ot Y\G ► S 1 �' PU ,Q`� FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:;
2.Well Construction Permit It: 3 ZS 5
List all applicable well construction permits(r.e.WC,County,State,Variance,etc.)iiftn wn
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 entonite Chips or Pellets
❑Geothermal(Heatmg/Coolmg Supply) Seesidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
01ndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout 17 Drill Cuttings
❑lni ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
— -❑Monitoring — -- — — t7Rccovcry--
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test OStormwater Drainage
oExperimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) OTracer
7g•Provide a brief descriptionof the a ndonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) ��`�` '`3 v�
4.Date well(s)abandoned: / J U L 2 ;-) 2022
Sa.Well location: Infonnalion Pmc" Una
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
Lt eo t `ryera�e CI T( J C6rne,! S A C-Z8631 7 20—Z.2
Physical Address,City.and Zip Signaime of Certified Well Contractor or Well Owner Date
`eL LQ u/`CP 00 -"' i 1-0 5 By signing this form, I hereby certify that the well(s) was(were)abandoned in
County �— parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in delta ces/minates/secomds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one Wong is sufficient) 9.Site diagram or additional well details:
N 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
Auachwellconstrudionrecord(s)ifavailable.Formallipleinjedionarnon-watersupplywelis
ONLYwith the same eonstructionlabandemnent,you can submit one farm.
10a. For All.Wells: Submit this form within 30 days of completion of well
6a.Well ID#: /v I,� abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 00 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: z (in.) above, also submit one copy of this form within 30 days of completion of well
2� 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): (B,) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submitone copy of this form within 30 days of completion
of well abandonment to the:county health department of the county where
6f.Inner casing/tabing length(if known): ((l,) abandoned.
6g.Screen length(if known): N/ (ft.)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gregory Boggs 7a.For Geoprobe/DPT or Closed-Loop Geothermal 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 needed. Indicate TOTAL NUMBER of
4514-C wells abandoned:t
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): C 1'0 (gal.)
S&ME, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
SIP# 70003035 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,County,State,variance,etc)ijknown
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 N Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
01rrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 5 pounds bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 5 pounds concrete
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Removed 1" PVC pipe from well, filled with
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
bentonite and capped with concrete.
4.Date well(s)abandoned: 7/7/2022 RECEIVED
5a.Well location: .1111 9 3 2022
Duke Power Company
Facility/Owner Name Facility ID#(if applicable) 8.Cer' ion: ifft ff1ibon Prod UM
410 S Mint Street, Charlotte, 28202 or "?N?2022
Physical Address,City,and Zip Sign e d Well Contractor or' er Date
Mecklenburg 07312411
By signing this form, I hereby certify that the wells) 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.
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:
35.22652 N —80.85025 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 constructionrecord(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construciion/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: G W-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (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:
10.30 (tt.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 5 (ft.) 10c.For Water Sunoly&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
6L Inner easing/tubing length(if known): (ft,) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016