Mecklenburg_Well Abandonment_20220830 (2)

•ELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Mtractor I ormation: WELL ABANDONMENT DETAILS
r; B 7a.Number ofwclls being abandoned:
Well Contractor Name(or well owne ersonally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
432AG construciionlabandonmeni,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):—' _(gal.)
l` y
U 1' kx&)s W.Q-A 0(1,W^,A FOR WATER SUPPLY WELLS ONLY:
Company Name �
l) 7c.Type of disinfectant used:
2.Well Construction Permit#{:
List all applicable well permits(i.e.County,Stale,Variance.Injection,etc.)ifknolvn D
7d.Amount of disinfectant used:"'Tk
3.Well use(check well use):
Water Supply Well: 7e.Scaling 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
tth nal/Commercial ❑Residential Water Supply(shared) kJ-1Tc-n—crete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation r � s
❑Aquifer Storage and Recovery ❑Salinity Barrier �
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer �j n�I /
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) �'� e 3 / i+ /w`e iu n_k K-!
4.Date well(s)abandoned:_ -7
5a.Well location:
FacilitylOWnerName Facility lI39(ifa plicable) 8•Certification: ;,^
992L/ 0/0 0--6� JR CH O& /IC 2,9 lily "?/)21 f� L—
Phys�icall Address,City,and Zip Signature of Certified 1Vefnqt.ractororl' win Date
/"
" "L if, y V O 31
'05' By signing this form, I hereby certify that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 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.'r Z Z 3 8 N a g o . 9 8 You may use the back of this page to provide additional well site details or well
0��
�'it abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Altach well construction record(s)if available. For multiple ii jectiott or non-water supply
wells ONLY with the same cmtsintctioa+abattdottmenl,you can submit oneform. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to die 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 I0a
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): !✓ (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
611 Inner casing/tubing length(if known): •/�_(ft.) where abandoned.
6g.Screen length(if known):__ / U (ft)
Form GW-30 North Carolina Department of Environment and Nau"l Resources-Division of Water Resources Revised August 2013

NME
WELL
A]B�® N a RECORD
For internal Use ONLY:
This form can be used for single or multiple wells
1.W 11 tntractor In atiou: WELL ABANDONMENT DETAILS
Well Contractor Name(or well owner p onally,abandoning well on his4ter property) 7a.Number of wells being abandoned:
For multiple injection or non-eater supply wells ONLY wiih the same
constniclionlahandonmeni,yolt can submit one form.
Well Contractor Certifi n nber n _ 01,
7b.Approximate volume of water rcmainiug in well(s): (gal•)
FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit# 7c.Type of disinfectant used:
: �
List all applicable well permits(i.e.Caunty,State,Pariance,Injection,eta)if know
3.Well use(check well use): n
7d.Amount of disinfectant used: 2,
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural PP Y)
❑Munic' lie ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RestLl 'dential Water Supply(single) ❑ Sand Cement Grout ❑ D Clay
Y
❑Industrial/Commercial ❑Residential Water Supply shared ❑ Concrete Grout
PP (shared) ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Rtell:
❑Bentonite Slurry W er ex lain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above, ovide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Ab `4S �
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g•Provide a brief escrip'on of ttte abandonme t procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
y� 1j"
4.Date well(s)abandoned: Z7/ l�Z� t?(I�JG
Sa.Well location: 2, �t
Facility/OwnerName Facili ID#Of7applicable) 8•Certifica ' AUG 3, 2�22
%�5 Lcx,SC v t,
Ini V�P3ii1 i^1 €'r c: •:a:r:9 2�
Physical A ess„ ity,and Z RignWa�— �ell3 !6� i-�� Contractor or Well (Tien)' Date
County By signing this form, I hereby certify that the tvell(s)ryas(were)abandoned in
Parcel Identification No.(PIN) accordance with 154 NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has beet:provided to the well Owner.
(ifivell field,one]at/long is sufficient)
9.Site diagram or additional well details:
3S�I S 3a) N i'yZ),7 glp� You may use the back of this page to provide additional well site details or well
��' abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS BEING ABANDONED
Attach well constntclion record(s)if available. For mtdtiple ityectimt or not-water supply SUBMITTAL INSTRUCTIONS
wells ONLY wild the same cmtslr?ictiottiabandonmeit{you 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 1 Oa
6e.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: 3 y (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (fL) IOc. For Water Supply&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): 1`� _(ft) where abandoned.
6g.Screen length(if known): (ft)
Force GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources
Revised August 2013