Mecklenburg_Well Abandonment_20220919

WELL ABANDONMENT RECORD For lnternal Use ONLY:
1.Wen Cmdeaetor In[eimatIon \X
7a.For Geop mbdDPT or Closed-Loop Geothermal Wells having the same
Wou Cantradar Name(or well ow=pmmally ab®do=S wail an Iiafha p.opaq well cm*ucLionMepth,only 1 GW-30 is needed. Indiame TOTAL NUMBER of
2 i - wells abandoned: _
NC Well Ca&Wwr Cain N=bcr 7b.Appavxixxote vohrne of water raoaloing In weli(s):
FOR WATER SUPPLY WELLS ONLY:
Cotnpw Names 7c.Type of dish Tech"used:
2.Wen CamtibKom Plravat#: A 0 `'J Q
List an appha6k wff.=far pandas fie M Cau.ty,Stars Yarimrcx e am)1'bw 7d.Amount of dishffecbant need: �!N
3.Well use(ehal<well us*
Water Supply Wan: 7e.Sealing naa6erhils used(check an that apply):
0Agricailtural pllrhmicapaUPuibhc p Neat Cement Groat ❑Bentonite grips or Pellets
Moubermal(Heating/Caoimg Sup*) tial Water Supply(single) E1 Sand Cement Grout [a Dry Clay
01ndustrialCommercial ❑Residential Water Supply(shared) 1 Concrete Grout ❑-Drill Cuttings
oftfiggtion ❑Specialty Grout o Gravel
Non-Water Supply Wen: ❑Benlonite Slurry p Other(explain under 7g)
0manituring ❑Recovery
Inijection wen X For r each undexW sad,acted above,panicle anaa®t dnaaterials used:
ClAquifer Recharge ❑Gramdwater Remedistim s tt» �?��1�.�t♦ ��1 �L��
pAquifer Storage and Recovery ❑Salinity Bauier
❑Aquifer Test ❑Skxm%aftr Draiasge
pExperimcatat Technology DSubsideace Carol 7g PaMile a idd description of the ahsndomst lsroein G
0Geothamal(Closed Loop) ❑Tracer 1 , aa (( a�:
❑G-1hermal ReLrm - under? �'UT \Y� �= `�L� �l c+"+j� V;�' ,
,L Date wens)ab.r,I md:_
51walnmm: 2ti2�i- 5Ut�1S�T �rcN! iT C-t1Z +'C 2 ���
VtRCSIH14 s c� u.�
Facility/Owner Name Fac�7iV ID#(if applicable)
C! ' 2 l
Physical Address,City,arAZip Sigastar f Certified well Contractor or Well Owner Date
tA E,cSL( U37-0/- 1- 0—f By sig>bW*s form.1 hereby cer*duet the wells)was (were)abandoned in
Coaoty Petal Wenfification No.(PIN) accordance with 1 SA NC!>C 02C.0100 or 2C.0200 Wet!Construmon Standards
aryl that a copy of this record has been provided to the well owner.
�i.Latidde and iaogltrde in deg�t+en/nitenirsldeeoods or decimal degrees-
(if well field,one lavlo%is milkient) 9.Site diagram or additional w R dabdW
N W You may use the back of this page to provide additional weIl site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELIAM BEING ABANDONED SUBMITTAL INS'1'RUc_'l'IONS
Anwhw UGanaWnc mreaord(s)ifavallable Foraadtlplerq/ecoonwa n +-wmrsappiy,adic -
ONLY with dos aurae aatrlryction/abardomwg you can submit oee,iorm. loot. For All Wells; Submit this fain within 30 days of completion of well
6a.Well ED#, abandonment to the following.
Division of water Reosuseer,halbam 1w Processing Unit,
6b Total well depth {g,) 1617 Mall Service Center,:Raidgh,NC 27699-1617
lob.For Infection Wells In addition to sending the farm to the address in l0a
6c.Borehole diameter. above,also submit one copy of ibis farm within 30 days of completion of well
abandonment to the following
6d Water level blow grand susfsrx: {g,) Dividon of water Resources,Un dergroand Injection
Control epwi ti
1636 Man Service Canter,Rskigln,NC 2709-1636
6e Outer nahig length(if known). {g) loc.For Water Sumuly&Infection Wc� In addition to sending the farm to the
_ address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county Imilth department of the county where
6E Inner casing/tubing bmg&(it known): /; abandoned
6g Screen length(if known):.
t of Environmental Quality-Division of Water Reso�aces Revised 2_22,2016
Form GW-30 1Vath Carolina Departmea