Iredell_Well Abandonment_ (6)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL.ABANDONMENT DFTAILS
Alfred Kiesling Jr. 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the saute
Well Contractor Name(or well owner personally abandoning well on his%her property) well construction/depth,only l GW-30 is needed. Indicate TOTAL NUMBER of
3266-A wells abandoned:-,
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): � (gal.)
B & K Well Drilling Inc FOR WATER SUPPLYWELLS ONLY:
Company Name C h I o ri n e
� 7c.Type of disinfectant used: l.�
2.Well Construction Permit#: J� �//3 6
List all applicable dell constnu•tion peewits(i.c. UK County.State. f i;riancc.ere)i/kno�-n
7d.Amount of disinfectant used: I (;�--
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal,Public ❑ Neat Cement Grout ZBentonite Chips or Pellet:
❑Geothermal(Heating/Cooling,Supply) @Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) Concrete Grout ❑ Drill Cuttings
0-Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentunite Slwty 7 Other(explain under 7e)
❑Monitorinn ❑Recover-
Injection Well: 71'.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediatlon
lt4 i3fr ►h,1t�l��
GAquifer Storage and Recovery ❑Salinity Barrier �—
CJAquifer Test ❑Storm Aater Drainage , �� �.Gre Y e
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) C]Other(explain under 7g)
1.Date well(s)abandoned: lv e2-Z w
5a��/Well location: 'Jcj 0 c 20
22
A
Facility/OwnerNatne Facility ID=(if applicable) 8.Certification: InkilVI12lFc:1 11-1
Dv-
Physical Address,City,and Zip --`
p Signature of reified�4'ell ntractor cr V .�O,,ner Date
t fill
S By stgnuto leis Jane., /1lerrby'cef"li1i-that the wells) tress h+-ere) crbardnr:�ed:n
County Parcel Identification No.(PIN) accordance with 15.4 NC,4C 02C.0100 or 3C.0200 Well Construction Standards
and that et copy qj this record has been prodded to the wail owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one laulong is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or wcil
N abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBI•IITTAT,INS'rRUCTIONS
Ane:ck well cons•rruction rre•ord(.c)if orailahle. For ntulnj�le it jacrion or nox-Y:atr:sups;.�,eli.;
ONLY pith the some ronsiracrior✓abando.nmP+;t.you rat,submit ore fbrm.
10a. For .all Wells: Submit this form within 30 days of completion of well
6a.Well 1D#: abandonntcnt to the followine:
e Division of Water Resources,Information Processing Unit,
6b.Total well depth: U , (ft.) 1617 Mail Seri-ice Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: (in.) above, also submit one copy of this form within 30 days of completion of Weil
abandonment to the following:
h
6d.Water level below ground surface: 40 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 1fail Service Center',Raleigh,NC 27699-1636
► �}�
6e.Outer casing length(if known): (ft,) lOc.For Water Suoph &Lniec6on Wells: In addition,to sending the form to the
addresstes)above.also submit one copy!of this font within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ftJ abandoned.
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I
6g.Screen length(if known): (ft.)
r„rn GW'-30 North Caroline DeparUvcnt u(=ncironmcnta!Ouaiity-Division of Watcr Resources Rcv,scd 2-22-2u!',