Mecklenburg_Well Abandonment_ (11)

WELL ABANDONMENT UCOiVJ orinterna se NLY:
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1,Well Contractor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some
Well Contrector 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 We► Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
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C C/ I! l' C FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2,Well Construction Permit#: lop �O
List all applicable well construction perm is 6.e.UIC,CougA,,,,S ft o
�,� � � q 7d.Amount of disinfectant used: D�
3.Well use(check well use): �°[�"
Water Supply.Well: i (� y l- 7e.Sealing materials used(check all that apply):
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❑Agricultural ❑Municipal/Public uDR ❑Neat Cement Grout entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) t}AnSedr�``terS� (single) ❑ Sand Cement Grout ❑Dry Clay
❑Indtistrial/Commercial ❑Residential-Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑lrri ation ❑jSpecialty Grout ❑Gravel
Non-Water Supply Well: ❑ entonite Slurry ❑Other(explain under 76
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:i
❑Aquifer Recharge []Groundwater Remediation �� � S
.❑Aquifer Storage and Recovery OSalinity Barrier —� p1
❑Aquifer Test ❑Stormwater Drainage (--
❑Experimenta)Technology ❑Subsidence Control
7g.Provide a briefdescription of the abandonment procedure:
❑Geothermal(Closed Ltiop) ❑Tracer /► A)I � ��
❑Geothermal(Heating/Cooling.Retum) ❑Other(explain under 7g)
4.Date well s.abandoned:
So.Well location:
Faciliiy/OwnerName Facility M#(if applicable)
Ph s' 1 Address,City,and Zip Signature of rtified Well Contractor or Well Owner Date
By signing this form,I hereby certo that the well(s)was (mere)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.
9b:Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwel�d,one lat(lodg is sufficient) .9.Site diagram or additional well details:
N tT 0D �1 r W You may use the back of this page to provide additional well site.details�or well
y abandonment details. You may also attach additional pages if necessary.
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CONSTRUCTION bETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
4ttaels well catstrucl/or records)tfavallable.For multiple tglection or non-wale rsupply wells.
ONLYtwlth the same a truetion/abandonment,you can submit oneform.
10a. For All Wells: 'Submit this form within 30 days of completion of well
6m Well ID#: abandonment to the following: `I
Division of Water Resources,Information Processing Unit,'•
6bi Total well depth:. ` (ft.) 3 .1617 Mail Service Center,Raleigh,NC 27699-1617 L10a
10b.For Iniection Wells: In addition to sending the form to the address
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: (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):. !l (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
abandoned.
6E Inner casing/tubing length(if known): (ft.)
.6g.Screen length_(if known): (ft.) i
'Furth 4W,30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016