Cabarrus_Well Abandonment_20221114

M LL�A��QN�NT RECORD D For internal Use ONLY:
This form can be used for single or multiple wells
1.W_ el(Contracto70,
rmation; WELL ABANDONt�IEi 7 DETAR S(�1',.l{,s
7a.Number of wells being abandoned:
Well Contractor Nam c for well or er personally abandoning well on his/her property) For multiple injection or non-water supply yells ONLY with the same
, �3 i cons/rnction/abatdomnew,you call submit onefornr.
aNcll Contractor CerticanonNumber / 7b.Approximate volume of water remaining in well(s): / _(gal•)
ynt'k-'W-S WLQ A J ' l� 131 F7c.Type
ATER SUPPLY WELLS ONLY:
Company Name
of disinfectant used:
2.Well Construction Permit#: C. _J
List all applicable well permiiv(i.e.3.Well use(check well use): Cnmuj.State,,irariatcr,h jectton,etc)ifditaun
7d.Amount of disinfectant used:
--
Water Supply Well: 7c.Scaling materials used(cheep all that apply):
❑Agricultural
❑Municipal/Public ❑Neat Cement Grout T"!�' I;," E 011 je�7 Bite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ❑ Sand ementGrout Grout L�-, d•._- t p Dn`Clay
❑Industrial/Commercial ❑Residential Water Su Iv shared I Concrete Grout:
Pp (shared) NOV I l:t]Prill Cuttings
FOAquifer
❑ Specialty Grout LL�U❑�! Gravel
r Supply Well:
❑Bentonite Slurry 1Tb'�Cori ucm tPmcz
g ' Explain under 7g)
❑Recovery
ell: 7f.For each material selected above,provide amount of materials used:
echarge ❑Groundwater Remediation Z � S
torage and Recovery ❑Salinity Barrier —
❑AquiferTest ` ❑StormmaterDrainage
❑Experiumental Technology ❑Subsidence Control
7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
_ Q r .�p �n
❑Geothermal(Heating/Coolin_Retum) ❑Other(explain under 7g) kit�i '�/ 3 / ,'✓1 y� e J
/J J
4.Date well(s)abandoned: Q Z$12z,
5a.Well location-
Facility/Owner Name a E.Certificatio .Fagility 1 -(ifapplicable) �/ q
3-732 'S�) o� /J�I , U��UJJ �Q(�jr, 20 /2,2--
Physici'gddress,City,and Zip tlIAj` Z�Q J(,p Signature ofCettifi We tractor or Well Owner Date
By signing this orm, I hereby cert that the mrell(sJ mvas(were)abandoned in
County Parcel identification No.(PIN) accordance with 15A AtCAC 02C.0100 or 2C.0200 Well Construction Standards
5b•Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copv of this record has beets provided to fire lrell owner.
(if well field,one ladlong is sufficient) 9.Site diagram or additional well details:
2��• yt05 9 g N — gD, �� I `y 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 NITLL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well conviruction recad(s)rf available. For multiple injection or non-water supply
wells OJVI Y with the same conshttctiotdabartdamtenl,you can submit rue form.
10a. For All Wells: Submit this form within 30 days of completion of well
62.Well IDg: abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth: (ft•) 1617 Mail Service Center,Raleigh,NC 27699-1617
l Ob.For Injection Wells: In addition to sending the form to the address in I Oa
6c.Borehole diameter: (in•) above,also submit one copy of this form NJthin 30 days of completion of well
abandonment to the following:
e 6d.Water level below ground surface: V (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): L� (ft) 10c.For Water Supply& Injection S'Vells: In addition to sending the fornm 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
6L Inner casing/tubing length(if known): (ft) mtimere abandoned.
6g.Screen length(if lmown): 1 1 f1 (ft)
-r
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources
Revised August 2013