Iredell_Well Abandonment_20220808

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
D5 h ZW(Ak K 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
p t / wells abandoned:
l� t f
NC Well Contractor Certification Number 7b.Approximate volume of water 'remaining in well(s): (gal.)
A006t n FOR WATER SUPPLY WELLS ONLY:
Company Ame
�� 7c.Type of disinfectant used: ✓1,�v, vuK i� , 1 �Y`�l�
2.Well Construction Permit#:
List all applicable well construction permits(i.e. UIC County,State, Variance,etc.)ifbrown 1 2 5 Z
7d.Amount of disinfectant used: 1 ✓
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout t7kIlentonite 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
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 Y1
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer �'�( i r
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) (Ao4-`(
4.Date well(s)abandoned: �;, CC f �1
5a.Well location: p U G Q O 2022
Facility/ m nerNa Facility ID#(if applicable) 8.Certification: into, [ 1�aiQ/'c3�018OG�` Un"
�
lad b)Mh6( f R Dv. Moot&�1�► c g 1 I'j yea�, S 2-J.a
Physical Address,City,and Zip qvq —,58 ``��1(,�I� Signature tfCertified Well Contractor or Well Owner Date
— By signing this form, 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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well.!details:
51M2 N W You may use the back of this page to provide additional well site details or well
'—t (�(� �/ 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:
02 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection 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: 3© (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&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
6L Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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WELL ABANDONMENT RECORD For Internal Use ONLY:
4'
1.W ll Contractor Information: WELL ABANDONMENT DETA{II.,S
7a.For Geoprobe/DPT or Closed;Loop Geothermal Wells having the same
Well Contractor Name(or w 11 owner personally aban ing well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 76.Approximate volume of water remaining in well(s): (gal.)
rACA 1 Wll A-B VI;AC. FOR WATER SUPPLY WELLS ONLY:
Company N ra� Cl-hb y�n
��a 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc)if known
7d.Amount of disinfectant used: V
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout EpBentonite 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
❑Ini 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 pf tQx�a�s�P= E :c
❑Aquifer Recharge ❑Groundwater Remediation `.•!L._
❑Aquifer Storage and Recovery ❑Salinity Barrier oAl3 8) 202?
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control lnfyr�1-'4C'I Pf `5,g Ure
7g.Provide a brief description of the abandonment pokkQ OG
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: �� �Q
5a.Well location: VJ /1 .I �� `"��
�h Furl h�v V 1 i `� 1
Facility/Owner Name V Facility ID#(ifapplicable) 8.Cer' Cation:
C5 a a 2,
Physical
/Addddre`ss, ity,and Zip Signature of Certifi f
Well Contractor o ell Owner Date
�,�'�+►� By signing this form, 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 well field,one lat/long is sufficient) 9.Site diagram or additional well details:
3C, ,n S[ 1 O N Q h ��0 Q W You may use the back of this page to provide additional well site details or well
Ul O (l L 1 abandonment details. You may also'attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)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
1 n 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: V/ (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&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): (ft.)
a.,...,rnv_zn North r—iina n>nartm>nt of Fnyimnmrntal natality-nivisinn of Water Resources Revised 2-22-2016