Iredell_Well Abandonment_20220930

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WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
2u)a f 7a.For Geoprobe/DPT or Closed Loop Geothermal Wells having the same
Well Contractor Nam (or well wner personally abandoning well onhis/her property) well construction/depth,only 1 GW
wells abandoned:
is needed. Indicate TOTAL NUMBER of
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NC well Contractor Certification Number 7b.Approximate volume of waters remaining in well(s):
/clqopl M1 FOR WATER SUPPLY WELLS'ONLY:
Company NanV t��'1GI'li 1
^� J ����� © 7c.Type of disinfectant used: i
2.Well Construction Permit#: f/4�
List all applicable well construction permits(i.e.UIC County,State,Variance,etc)ifknown
7d.Amount of disinfectant used:: f72
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that appli ft
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout g Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) LKesidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Ini ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply '� `R'"
PP Y Well: �-'� �O&Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: F pp O ZQZ 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Re'U: tioh J
" S Co M0 lb
❑Aquifer Storage and Recovery ❑Salinity B rr r-- .s a:.. 01 rr. �
❑Aquifer Test ❑Stormwater DrainageJt Ot".] '
❑Experimental Technology []Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer p
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) , J u (b be tl l o `OLl-, ►r/ m C rue(�l
��C�tCC�I A- C mnf1rc> Jicil(i�t'G� (' tl.'QI�
4.Date well(s)abandoned: 1
F;[IA Lk' ywuwo(');K �vrlm' 'e& twn on��e
5a.Well location: t
t�"veeA
ictorli Oil (S
FacilityFacility/�e Facility ID#(if applicable) 8.Certification:
° )q Ugh SF �{C'ker,UL &)C �L%7-7 ; a—
Physical Address,City,and Zip Si e of Certifi We ontra o of Well Owner Date
y signing this form, I h y or
that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with ISA 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 well field,one lat/long is sufficient) 9.Site diagram or additional well details:
1 N �(� V W 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,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,
^ 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
101b.For Infection Wells: In addition to sending the form to the address in 10a
t^6c.Borehole diameter: (in.)
above, also submit one copy of this form within 30 days of completion of well
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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): X (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one icopy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): (ft.) abandoned.
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6g.Screen length(if known):
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