Mecklenburg_Well Abandonment_ (10)

WELL ABANDONMENT RECORD For Internal Use-ONLY:
1.Well Contractor Info adon: u WELL ABANDONMENT DETAILS -
2 7a.For GeoprobelDPT or Closed-Loop Geothermal Wails having the same
Well Contracto ame(or well owner personally abandoning well on his/her property) well construction/depth,only 1 6W-30 is needed. Indicate TOTAL:NUMBER f
wells abandoned:
NC Well Contractor Certification Nu r 7b.Approxitnate volume of water remaining fa well(s): �(gaL)
FOR WATER SUPPLY WELLS ONLY:
Company Name
I yry 7c.Type of disinfectant used:
2,Well Construction Permit#: ���[��/
List all applicable well constMetloh permits O.e.U1C,Coun%State,Variance,etc.)Jfknown
7d,Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):,
[]Agricultural ❑M pal/Public ❑ Neat Cement Grout ntonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Lndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑(hill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑'Bentonite Slurry ❑.Other(explain under 7g)
❑Monitoring ❑Recovery
Tiijection Well: 7E For each material selected above pro de am unt of materia used:
❑Aquifer Recharge ❑GroundwaterRemediation �
.❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:'
'OGeothermal(Closed LdoR) ❑Tracer c d
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) stap
t
4.Date well(s)•abandoned: 1V_ ?P6_;y
so. lllocation: p��r, i,,AZT "
R
tl
Facility/Owner Name Facili ID I(if applicable) 8.Certi ation:
f PT
Physical Address,/City and Zip Signature of Cerdfifd Well Co4racto'r or Welr6wner Date
GBy signing this form, I hereby certo that the well(s)was(trere)abandoned in
County Parcel Identification No.(PIN) accordance with I 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:
(if. ell field,one lat/lodg is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
iv
L ® +'� W abandonment details. You may also attach additional pages if necessary. i
9ONSTRUCTION(DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(r)irawllable.For multiple infection or non-water supply wells
ONLY with the same c •rerction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of we11
6a'.Wel11D#• abandonment to the following:
�✓ Division of Water Resources,Information Processing Unit,
6b:Total well depth:. / (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
'6g'BDrehole diameter: (in,) above, also submit one copy of ithis form within 30 days of completion ofiwell
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
Outer casing length if known); (ft.) 10c.For Water Suuoly&Infection Wells: In addition to sending the form Lthe
6 e.O g g ( ) 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): Ag, (ft.)
furm GW-30 North Carolina Department of,Environmental Quality-Division of Water Resources Revised 2-22-2016