Mecklenburg_Well Abandonment_20220815

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-hoop Geothermal Wells having the same
Well Contract r Name(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:
NC All Uon&ctor Certifi ation Number 7b.Approximate volume of water remaining in well(s): 4,41 (gal.)
SY I L �G FOR WATER SUPPLY WELLS ONLY:
'Company Name
7a Type of disinfectant used:
2.Well Construction Permit#: `
List all applicable well construction permits(:.e.UIC,County,State,Variance,etc.){/'known
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 ❑ Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commemial ❑Residential Water Supply(shared) �oncrete Grout ❑Drill Cuttings
❑ha ation ❑ Specialty Grout ❑ Gravel
Non- ter Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g) r
onitoring ❑Recovery
Tnjection Well:, 7E For eact material selected above,provide amount'of materials used:
❑Aquifer Recharge ❑Groundwater Remediation ` C }. el �p
.❑ e Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control i
7g.Pr d brief description of the abandonment procedure:
❑Geothermal(Closed I,00p) ❑Tracer � �C
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 11 // /
4.Date well(s).abandoned: - 0 202
511. . ell location:
lif_ •-.-,'7t-ter.,:..z,.abue c, I tni2
Facility'/Owner Name Facility ID#(if applicable) 8.Ce fleation:
M2
Physical Address,
°City,and Zip Signature of C 'fied Well Contractor or Well Owner Date '
By signing this form,I hereby certify,that the well(s) was(were) abant ed in
County Paicel 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 loftgitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lodg is sufficient) 9.Site diagram or additional well details:
�O N tJ „Q�G) �W You may use the back of this page to provide additional well site details or well
p —4 .t/ � abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION 6ETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructio•,qirecord(s)(javallable.For multiple injection or non-water supply wells
ONLY with the same cdpstnretton/abandonment,you can submit one jorm' 10a. For All Wells: Submit,this form within 30 days of completion of well
6a.Well ID#: U abandonment to the following:
Division of Water:Resources,Information Processing Unit,
615i Total well depth:. (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 '
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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: (fG) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699�1636 1
6e,Outer casing length(if known): (ft.) 10c..For Water Supply&Infection 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): (fG) abandoned. I
.6g.Screen length,(if known): (ft.)
Furm OW,30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-2 -2016
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WELL ABANDONMENT RECORD ForInternelUsoONLY: �►
1.Well Contractor Information: WELL ABANDONMENT DETAILS
1e �11 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
wells abandoned: '
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
FOR WATER SUPPLY WELLS ONLY:
Company Name
I 7c.Type of disinfectant used:
2._Well Construction Permit#:
List all applicable well construction permits(t.e.U1C,County,State,Variance,etc.)(fknonm O h
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 ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement.Grout ❑Dry Clay
❑IndiistriaVConunercial ❑Residential Water Supply(shared) oncrete Grout ❑Drill Cuttings'
❑hri ation ❑ Specialty Grout ❑ Gravel
Non- ter Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
onitoring ❑Recovery
:injection Well: IFE For each rltaterial selected above,provide amount of materials used: M
❑Aquifer Recharge ❑Groundwater Remediation y ! �t
.❑Aquifer Storage and Recovery ❑Salinity Barrier a �J ��Te —j—
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief escription of the abandonment procedure:
❑Geothermal(Closed LooR) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s).abandoned:
Sa, ell location: •JTM ��"�
Fecil er Name Facility ID#(if applicable) Zercation:
Physical dress,City,and Zip Signature of qrtified Well Contractor or Well Owner Date
By signing this form,I hereby cero 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.
Sh:Latitude and longitude In degrees/minutes/seconds or decimal degrees: 1
(if well field,one lat/lorig 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 additionalpages if.necessary.
;
CONSTRUCTION 6ETAIL8 OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructlo�record(s)1f6vailable.For multiple injection or non-water supply wells
ONLY with the same coo}sstruction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of-wel
6a'.Well 1D#: abandonment to the following:
Division of Water Resources,Information Processing Unit, l►
6ti:Total well depth:. /1y (ft.) 1617 Mail Service Center;Raleigh,NC 27699-1617 I
10b.For Iniectlon Wells: In addition to sending the form to the address,in 10a
6c:Borehole diameter: pn,) 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 Resourcesi Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636''
6e,Outer casing length(If known); (ft.) 10c.For Water Suunly&Iniection Wells: In addition to sending the form to the
addresses)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 Of known): (ft) abandoned.
6g.Screen length(if known): (ft.)
. i Revised 2-22-2016
Form OW30 North Carolina Department of Environmental Quality-Division of Water Resources