Cabarrus_Well Abandonment_20220815

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WELL ABANDONMENT RECORD For Internal Use ONLY
1.Well Contractor Information: 1 WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sa e
Well Con�me(o well owner personally abandoning well on his/her property) well consttuctioa/depth,only 1 GW-30 is needed. Indicate TOTAL NUMB R of
wells abandoned:
6 7b.Approximate volume of water remaining in well($):
NC W i Contractor Certification Number
FOR WATER SUPPLY W19LLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:-- " � • — f
List all applicable well canstnrctiorr perm is O,e.UIC,Couno,,Si die,Yartance,etc.)(mown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout YV16entonite Chips or Pellets i
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial OR esidential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
at, ation ❑ Specialty Grout ❑Gravel
Non-Water Suppl. a ❑ Bentonite Slurry ❑ Other(explain.under 7g) .+
❑Monitoring Recovery
Injection Well: 1�`J ! :� ` 7L For each material selected above,provide amount-of materials used:
❑Aquifer Recharge Q �luD�r�e rAwater Remediation
❑Aquifer Storage and Rta t$Od❑Salinity Barriers .
�'
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed LooR) OTracer �{ 7
TP
❑Geothermal(Heating/Cooling Return ❑Other(explain under 7 ) �v' C e
)� J I'Plf
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A.Date well(s)•abandoned:
5a.Wo location:
Facility/AWner Name Facility ID#(if applicable) 8.Cer cation:
It
physical Address,,City,and Zip 02 R? Signature of Celdfied Weir Contractor or Well er Date
By signing this form,I hereby cert(jy that the wells) was(were) abandoned to
'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. i
Sb:Latitude and longitude in degrees/minutes(seconds or decimal degrees:
(if ell field one•Is od is sufficient) [/ l 9.Site diagram or additional well details:
�a J °� ; / You may use the back of this page to provide additional well site details or well
N Q
,7 rJ U Wabandonment details. You may also attach additional pages if necessary.
Y CQNSTRUCTION bETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS f
Attach well construcilo records)ii avallable.For multiple injection or non-water supply wells.
ONLY with the same c stnrctlon/abandonment,you can submit one form, 10a. For All Wells: Submit this form within 30 days of completion,of well
60.Well ID#: abandonment to the following:
Division of Water.Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6ti:Total well depth:. r y —(ft.)
10b.For Infection Wells: In addition to sending the form to the address in 10
above, also submit one copy of this form within 30 days of completion o�'well
6c:Bbirehble diameter: (in•) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
61 Water level below ground surface: (fb) 1636 Mail Service Center,Raleigh,NC 27699-1636
I0c.For Water Sunoly&Infection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft) addcess(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 whore
abandoned.
6f.Inner casing/tubing length(if known): 1
.6g.Screen length(if known):
Revised 2-22-2016
North Carolina Department of Environmental Quality-Division of water Resources
Form aW,30
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