Cabarrus_Well Abandonment_20220930

WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
kg't- T"da-4— l a r 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor 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: _d1L f
z/5f -
NC Well Contractor Certification Number 7b.Approximate volume of water`remaining in well(s): � c:�:�(gal.)
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4 Imp FOR WATER SUPPLY WELLS ONLY:
Company Nam r vo
7c Type of disinfectant used: ('"1 I.r-1
2.Well Construction Permit#: d��' �
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc)ifknown E
7d.Amount of disinfectant used:
v
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply
❑Agricultural ❑_Municipal/Public ❑ Neat Cement Grout entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 6Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: _ v, ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring _ Rweco, _"
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑A uifer Recharge 3 �gt$ odwater Remediation
4 g SFP 1b maul ., WIL
❑Aquifer Storage and Recovery ❑Salinity Barrier �+
❑Aquifer Test Ifliv� ie i'� ,hn Q �
ClS�torm ater Drainage
❑Experimental Technology ❑Suubsidence Control J
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) yuly?® up anck
a 1Ci i€476 Poh Cte4
q� c�
4.Date well(s)abandoned: 0, O Q
5a.Well location:
�f�c�i^�.�-�� r��lf�a� ��_ Cam►-�c� �p�r!
Facility/Owner Name Facility ID#(if applicable) 8.Certifica on:
Physical Address,City,and Zip re of Certified a on for r Well Owner D e
CU b e rr a S By signing this form, her �cer�tify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
15 d -15 N 'TQ s -I 0 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,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 Infection Wells: In addition to sending the form to the address in 10a
l i 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&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 where
6f.Inner casing/tubing length(if known): x (ft.) abandoned.
6g.Screen length(if known): N (ft.)