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Home My WebLink AboutIredell_Well Abandonment_20221222 ABANDONMENT RECORD North Carolina Deparbnent ofEuvironrrrent end Natural hesources-Division!of Water Quality I/f WELL CONTRACTOR CERTIFICATION# 1.WELL CONTRACTOR• _- s. WELL DETAILS: ?' nh02':il et�Me•s!ic��/ a-Totalbepth 12Jr':. it. Dismelar, in. Well Contractor,(Iriiiivlduai)Namhb.Waler Level(Belo*.Measuring Palnq:.� _% MCCALL BROTHERS,INC. ',':; `: Measudng point I : ft.above land surface. ;f Well Contractor Co pang Name I 6700 BROOKSHIRELVD. 6. CA51N6: Length Diameter I' Street Address 'il{':;': ;i /(� CHARLOTTE :+rl'`(. NC 262i fi �+ .is a.Casing Depth(IFknown): it in, r City or I°i. ! ::state Zi Coda: ! h.6,6INjRemoved:'. fl. In. 1 70�� 399-1506 4� r ! . i.•,•• �,,r i. e .,I D. 7. DISINFECTION: li�7 -i`YJ e_ Area code Phone llur'aber :j `: :A.;; 2.WELLINFORMAO 'f - 2 (�nodntaf65%75%;calclumriyl:ochlodleused) :i. : S. 'SFLiNG MATERIAL: SITE WELL ID#,(i(-bopDcabie) :{{,,,_ ;• S:: Nat . m-nt Sand Cement STATE WELLPERMIT# (If.eppllrxbi :Cement lb. Cement lb. COUNTY WELL-PERMIT *prappitcabla) G�.S I�_1Gt� :335.3: :'Water 1 gal. Water gal. r` ! Sentonite DWQ or OTHER?ERMIT 9(if applldable) 1` Beitlonitej7Gr'' lb. WELL USE(CheckappllcableuseO.M,oriitaring p e-sldendal . : 1.•Type:❑Slurry:W els ❑ Municipal/PuAck' ❑ IndustriallCoinmercial ❑ Agricultural Wale gal.' ❑ Recovery ❑•'injection ❑ Irilgation f! ;+Other ❑Other(list use):'•+i':• ,! Typ e material 'J•fl df•� ,� 1,b S I6 #i i.. 3.WELL LOCATION: COUNTY QUADRANGiE NAME :': . : i•'_ ;. ; NEARESTTOWN;+noor t5�f�:`f T �_ 9. FJfPLAINMETHOO.OFEMPLACEM NTOFMATE IAt: it✓ S�yj: 1� �i/f.f.s't� %//c� - �f/7 -- Y'�— - � �is StreellRoad Name{-Number n,Lo,6rnmuMy,Subdivisrc 9�31.r�G p��' - ( t No.,Ps Parcel,7!p Coda) TOPOGRAPHC/I Nb SETTING: ` '' ❑Siope ❑vallai;?4�r lat� ❑.RidgedOth'a: ' ! (Check eppropriale selling) 10. WELL DiAGRAM:Draw a detailed sketch of tiveell on the back of this •��y'IT. form� form showing total depth,depth and diameter of screens(If any)remaining LATITUDE ' L">=� �OIiAS'OFi 3X.XXXxxamoU 'Inithe well ravel inteival Intervals of casingerIbratlons and depths and LONGITUDE, tj S' .i (i M5 'OR 7X.X3000t)oOg4p types of lill maledaWie'd P P LaDtudellongttude s ounce: C PS�Dropogtaphlc map I ': .�� Z —z,, (/ocalfon of well mU., a shown 11. DATE WELL ABANDON on a USt3S fopo map andatlachedto Eb; this fomr Nnaf uslrig GPSJ `. ''• I DO HERESY•CERTIFY THATT.Ht6 WrzL.WAS ABANDONED IN A000RDANOE !!f WITH U RCAC 2C,WELL CONSTRUC'(ION STANDARDS,AND THATA COPY OF 4s.FACILITY•Theni.c 4iorlhebusinesswhsrethervellisloratad.Complets4ar- ::: THSREdORDHASBEEN:PibV!DEDTOTHEWFILOWNER. ¢re msfdsnQalweR.skip4a;mmptate4b,hil dwrierinfannaUononly.} :.'. FACILITY ID# (1fappllcabfe) j.'' NAME OF FACILITY!. SIGNA�IRE OF CEWIED:WELL CONTRACTOR DATE STREETADDRE SIGNATUREOFPRIVATEWF.LLOWNERABANDONINGTHEWELL DATE City orTown ! i State Zip Code (The pdvaiaik4ownermusthednfndMdualw smo ett bandonshisiherresldentlalwag {' r InsccordancdwRhl5ANCAc'i2C.0113.) 4b.CONTACT PERSONfWELL OWNER: . .: 'r`"$o J _ti5 c+/4_ i1 V l: /7.':: e t1 NAME- PERSON ' p t /� 111 r PRINTED NAME OF PERSONA NDONING THEW E LL STREET ADDRESS`. `7 CI'�` li,C• "ra �/G"Cr rrr'-`t "{.•Y�:ZfLL.Jr:iltir?—:b�;:='"'?%��'.;�4:ti l.�.i��f.�i;t C•'%,+'-•i• rr�'i•i':?i:yy r.T :�r•.i.�.:''`:::�F.��croyr,k>::^•ai��:,F:••sY•,`�?r:�i••�v...at.:,i:. e i .Ct �i.:' i{r`• �.;..4'.••i� ,. ,.a,„.,,..'C,,, r!, b�•i'3'•v.•,m ti!;:•.i•. L:S it stilt ascoPy�o!1(aerrowne an ii eoriginaiter•*:'.,a6i.r'f.o-r7,r,.lV,l.ai�:Saa•erI;r,rS�,d�r�:ich�e'wd auC,S•ti4e rr r�tei'etrY+''!`R6'yar7'Se i rg„ir;1+T6::•t:Ca'.}`-'2•L�'+a•e h,...•..:• .:u oi iieis;l.�.io'9i1aa9�8lf0SL7rt6e3..30.Q05�7't a..tl�ti}Y{.•i; o=+i.;t;a r:.::.;: ' .v"r+e,rs.;:•:. r' Far m GW-30 76 67 Rev.Tim. 5110is'i'::.ai' :.i. ir.,:f:. ..t,i::. •:t�i .<.:• .:R::.:1 : .:+-::!°ts.• ., rl }A te..t.r:. .. WELL RECORD YVL'LL ABANDONMENT RECORD For Internal Use ONLY: This form can be used for single or multiple wells 1.Well ontractor In mation: WELL ABANDONMENT DETAILS �S a ,✓ 7a.Number of wells being abandoned: Well Contractor Name(or well owtJ personally abandoning well on his/her property) For multiple injection or non-il wter supply wells ONLY with the same (�. eanstruciion/abandonmenl,you can submit one form. 13� NC Well Contractor Certification Number / 7b.Approximate volume of water remaining in well(s): I S RCN\ '�_)(j W^ FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: 2.Well Construction Permit �'OZ� 7 List all applicable well permits(t.e.County,State,Variance,Injection,etc.)ifkno wit i 1 c 1 , 7d.Amount of disinfectant used: 3.Well use(check well use): , + S +d �. Water Supply Well: nE:r n 2 2022 7e.Sealing materials used(check all that apply): ❑Agricultural ❑Municipal/ bite (� ❑Neat Cement Grout ❑Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) 1aR i % atccpSppp.ly.(sj0 4 lJ1 W Sand Cement Grout ❑Dry Clay ❑Industrial/Commercial ❑Residential WaivigebWsRared) ❑ Concrete Grout ❑Drill Cuttings ❑Irrigation ❑Specialty Grout ❑Gravel Non-Water Supply Well: ❑Bentonite Slurry kLLj0d er(explain under 7g) ❑Monitoring ❑Recovery Injection Well: 711 For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation 7�71 —�,1� 6► ,e ❑Aquifer Storage and Recovery ❑Salinity Barrier L ®�� ❑Aquifer Test ❑Stormwater Drainage ❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer �^�• Q ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) lexccq V —fi 1 J r��[y ate/ CS het�D n ] CTT 4.Date well(s)abandoned: 1� 1 w 4 Z 0.,d/{ 5a.Well location: hmn YyIAf g Facility/Owner Name Facility ID#(ifapphcable) S.Certification: 11A <Je wG►�) Q� � i e �C, ZBIIc:� Physical Address,City,and Zip e� Signature of Certified W --4- Con for or Well Owner Da 2� 1 0� '� By signing this form, I hereby certify that the ivell(s)was(were) abandoned in County Parcel Identification No.(PIN) accordance ivith 15.4 NCAC 02C.0100 or 2C.0200 Well Constniction Standards and that a copy of this record has been provided to the ivell 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: You may use the back of this page to provide additional well site details or well N W abandonment details. You may also attach additional pages if necessary. CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS Atrach well construction records)if available. For multiple it jectian or non-water supply irells ONLY with the same cat,tnrct' t abandonment,yot can setbntit ore form. 10a. For All Wells: Submit this'form within 30 days of completion of well 6a.Well ID#• t abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: �) YQ 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Iniection Wells: In addition to sending the fort to the address in 10a above,also submit one copy of this form within 30 days of completion of well 6c.Borehole diameter: (in.) abandonment to the following: r / ' 6d.Water level below ground surface: / (fo Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): 1 tl (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 6f.Inner casing/tubing length(if known): (ft.) where abandoned. 6g.Screen length(if known): (ft) Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013 i i