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Home My WebLink AboutMecklenburg_Well Abandonment_20220830 WELL ABANDONMENT RECORD This form can be used for single or multiple wells For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT DETAILS r- Well Contractor Name(or well OwH6 personally abandoning well on his/her property) 7a.Number of wells being abandoned: For multiple injection or non-water supply wells ONLY with the same construction/abandonment,you can submit one form. NC Well Contractors Certification Number 7b.Approximate volume of water remaining in well(s): al -D L, M i-t L. 1 W S (g ) '�� 1 r 1 1Y FOR WATER SUPPLY WELLS ONLY: Company Name _ / > 2.Well Construction Permit#• ( �� 13 J v�? 7c.Type of disinfectant used:_.I List all applicable well permits(i.e.County,Slate,Variance,Ii jecuon,etc.)if known 7d.Amount of disinfectant used: 3.Well use(checkwell use): Water Supply Well: 7e.Scaling materials used(check all that apply): LOGeothermal ltural pp Y) ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets (Heating/Cooling Supply) LBt e�ntial Water Supply(single) ❑ Sand Cement Grout ❑ D ,r} Clay ial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings on ❑ Specialty Grout Non-Water Supply Well: ❑ Gravel ❑M onitoring ❑Recovery ❑ Bentonite Slurry L-4 Other(explain under 7g) Injection Well: 7E For each material selec d above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation❑Aquifer Storage and Recovery ❑Salinity Barrier (!( ❑Aquifer Test ❑Stormwater Drainage ❑Experirnental Technology ❑Subsidence Control ❑Geothermal(Closed Loop) ❑Tracer 7g•Provide a brief description of the abandonment procedure: ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) / xtG c 6_10 CJd t�K'l� 4.Date well(s)abandoned: ZL �5a.Well location: Facility/JOw—ery me p / Facility ID9(if applicable) 7�'' 8�.JCertifieation A�Jr J Zl'ZZ �( 1�tsN�t � �t�Physical Add es Iilrui�Tit;�"w0�1r'P3C@,,'-..l.Zs;?��f'a s, i ,and Zip /I Signature of Ce d Well ontractor or Well tlwner ' v2— ��H�4 Date sSr' yZr 3 County By signing this form, I hereby certify that the ivell(s)was(tvere)abandoned in Parcel Identification No.(PIN) accordance with 15.4 NCAC 02C.0100 at-2C.0200 Well Construction Standards 56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner. (ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details: 3 S • Z l'3 9 b N ^�O. SS �� You may use the back of this page to provide additional well site details or well W abandonment details. You may also attach additional pages if necessary.CONSTRUCTION DETAILS OF WELLS BEING ABANDONED Attach 1vell construction records)if available. For multiple it jection or non-haler srtpply SUBMITTAL INSTRUCTIONS wells ONLY with the same constnrctionlabandonmem,you can submit one farm. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#: abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 1Ob.For Iniection Wells: In addition to sending the form to the address in IOa 6c.Borehole diameter: Z_ (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): (ft) 10c.For Water Supply&Iniection 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 6f.Inner casing/tubing length(if known): (ft) where abandoned. 6g.Screen length(if known): —A� (ft) Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013 WELL LL A13A A/o17MEN d RECORD For Internal Use ONLY: This form can be used for single or multiple wells 1.Well Contractor Information: WELL ABANDONMENT DETAILS S P 1 Ct 4 9J 7a.Number of wells being abandoned: Well Contractor Name(or well d1ner personally abandoning well on his/her property) For multiple injection or non-hater supply 'wells `ONLY with the some construclion/abandonmew,you can submit one form. NC Well ContractorCertification Number 7b.Approximate volume of,water remaining in well(s):� al,�_cg ) FOR WATER SUPPLY WELLS ONLY: Company Name / 7c.Type of disinfectant used:- YZ,y 2.Well Construction Permit# List all applicable well permits(i.e.County,Slate,Variance,Infection,etc.)ifhuowu �f • '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) �tial Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay ❑lndustriaVCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings ❑Irrisation ❑Specialty Grout ❑ Gravel Non-Water Supply Well: ❑Bentonite Slurry LB @ifier under 7 ex lain a ❑Monitoring ❑Recovery (explain p �) Injection Well: 7E For each material)select above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remedi ation ❑Aquifer Storage and Recovery ❑Salinity Barrier `/ ❑Aquifer Test ❑Stormwater Drainage ❑Experimental Technology ❑Subsidence Control ❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure- � / _[}• ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 'r� e ►� f4�t C a7T - 4.Date well(s)abandoned: (�5a.Well location: � )� Jy �� AUG 3 J 2022 /l ZZg�� ++�t �h QfL.V1 ��l 1 T Facility/OwnerN to Facility ID#(if applicable) ' 8•Certi£cation: InfvrYe�««011 pi'�'h w,!;.�ng Unit Physical Address,City,and Zip Signature of Certified\Veil Contractor or Well Owner '^ Date County By signing this form, .1 hereby certify Mat the ivell(s)ivas(were) abandoned in Parcel Identification No.(PIN) accordance with 1 A NCAC 02C.0100 or 2C.0200 Well Constniction Standards 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy ofthis record has beenprovided to the well turner. (ifwell field,one lat/long 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 N '�S ^� W abandonment details. You may also attach additional pages if necessary. CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS Atlach well construction record(s)if available. For multiple injectimn or non-water supply wells ONLY with the same constructimniabandonment,your can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#: 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 Injection Wells: In addition to sending the form to the address in 10a 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: s [ft.) Division of Water Resources,Underground Injection Control Program, r 1636 Mail Set-vice Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): (ft) 10c.For Water Simply&Injection 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 6f.Inner casing/tubing length(if known):-- (ft•) where abandoned. 6g.Screen length(if known): / \ (ft) Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013