Mecklenburg_Well Abandonment_20221222

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�(�y.y�� ,, •-Norvth Colrn a Depnrment ofEnvironnentandNatutuR
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"of uilil�s-D' n
4""�• �'` WELL CONTRACTOR CERTIFICATIONS� J LZ`4
1.WELL CONTRACTOR: ?' S. WELLDETAiLS:
"'I „ • j a.Tolal De ih t�
��� .••I�� • ` P �tt. Diameter in.
Well Contraclar,(Indl�ldual)Name r b,Gf►alei Leve1(BelowMeasirring Polnl):_ �ft.
MCCALLBROTHE�RS,INC, '`' '
''• ;Measuring point 19:& _L above land surface,
Well Contractor Co•"p q Name et
6700 BROOKSHIRE 6LVD, '. `' 7 f
I. CASING: !' Length Diameter
Street Address.
C ui��;l; 3 ;:• 1 i
HARLO T TE .f i,i '4'
e:'j'�. NC. 28216 !% .';: 2.Cosing Depth Ofkiicvm): %V It. in,
CltyorTown .;ry'r�; ! %. 'f +:State ZiPCode' ' h,yCasirigRemoved:t, " ft. In.
70 4 1 399-i506 j'c 4 . ';t f ,.! : ;.� :• .
Area code Phone nilinber , 7. DISINFECTION• '/ a 2
Z.WELL 1NFORMA7l0�tr ' ; % r .;; (A�ti(ieunt of 65%75%calcium liypochlorite used)
SITE WELL ID&-iOfapplipable) ; B. SEALiNG MATERi1(L�
STATE WELL E il',"' '(Ifep kcable) :� Neac .a+nont G�nd Gpmpnt
l:tl ; i Cement '` lb. Cement lb.
,.•r ;'Water
COUNTYWELUPERMiT #(lfappllcable) '/Cis) ��?s 05.. t f :!r gal. Waler oah
e f. ,•.r
13WQ or OTHEK PERMIT 4(if appllcable). )
WELL USE(Check;appllcable use)[7;MoHltoring �Fiidentlal 8entonlfe/�j�' lb.
_
I.Type:❑Slurry:i repels'
❑ Mun(cipallPu6)�c •p lndustrTa11Cotnrnerclal' ❑ Agricultural Wale[ gal,'
❑ Recovery ❑1 jection ❑ irrigation ' `= G :; "' nu 2 Oi 2022
❑Other((Istuse):r:i:�' 'hit
ryPematerial Tn,•�;;r:
3.WELLJ.LOCATIOHt -Am
ount
•• COUN77
TY J�l� _-'- •QUAD RAN GtE NAME
NEARESTTOWI4..+: G�zgiJo-;/7� 9. •EXPLAIN METHOD OF EMPLACEMENT OF MA'fEFtIAL:
(ShesURaad Nam# Number,CommuNt Y,laubdivleloc to lNo.,Pereal,7�pCoda):'
TOPOGRAPHC/MbSETTING: '2
❑Slope ❑Valley,«; p RldgeO.Oliier
! (Check approprlale setting] ' i>
y, 11r. WELL DIAGRAM:Draw a detailed sketch of th+a3ll on the back ofthis
f" form showing total depth,depth and diameter of screens Of any)remaining
LATITUDE "/L'•�;l]M5 OR 3X.XXXX)DOr]cmD in�the well.gavel Inleivel,intervals of casing pelforallons,and depths and
;• LONGITUDE �.;; 'pM5 DR7X.X}O000D0M6 types affitmaledalsised
% CAPS o c is "
Lalltude0ongiludesou Llr p 'g' phlcmap I.;
't' 11. DATE WELL ABANDONED: I — 9 Z z
(/ocatfan of well mtisttie shown an a USaSlopo map andattachedlo •• r
this tram«Irnat using
(DOHEtif$Y.CERTIFYTHATINSWEI.LWASABAN06NEDINACCDRDANCE
ITHISA 4a.FACiUTY-'I'her!artteerttrebusinesswhatathewelilstoralad,Complats4er' :;: THISREC RD;HASHEEN;P�ViOEEDDTOTHEWELLOWNERNDiHATACOPYOF
((f a rstdanpelwetl,sk(g4a;lnmplela 4h,w®il ownartntannaUcn only,)
FACILITY 10#¢f appilcable) n IJ - ��� , 7 `�• ��
L k --s
NAME OF FACIL11Y)• /7 R = °[j },i =RE OF CWaRED•WELL CONTRACTOR DATE
STREET ADDRESS`! _71 y Cl_�J Jos �j^ �;f 'rf{
T SGNATl1REOFPRIVATEWEt_LOWNERABANDONINGTHEWELL DATE
Cityor�Lown ;= Stele ; ZIP Code ! ; [fhspdvalalgeUownermustGe fin lndhddualw ersa sn bandon.lib ermienitalweu
�'''" is ;•� Inearardinaavi5hi5AHCAC?C,D713,)'
4b.CONTACT PER50N1WELL OWNER: ,
NAME_ ZiL %il' r PRINTEEXNAMEOFPERSON NODNINGM4EWELL
STREETADDRESS i 461 7rf••Sff.'Ys.—
=l:% - :31':2;IGLJ!''eT:irj•+:r'R�:•�='�ic1Y::,.:;..1 �•.�.^'7-i a•;rt`J•', •s•ru• •: ,
SV� i,t3:C0 r,f 'r x �•�t�1s5,� : �_`.•t.:•y: . ',::• fir•. n:+ a:r�; r. rs��
m t' i?y"t0l.b c' 1 8T1U:u1�•OC r•i t.- �`;y ,..�.•.vn=•:;».y •,
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i� f. flE,d ,1!°ta4r•�[,y;.w; •dr ,tt: Jsrl7 su . v a =s 1@ClC H)1 a3', f rmatlgn`Process �.
y`.ai6ifs7rlVlal�:SertT[ceaCenfg r 1'i- C`2 6 •,,' ' Form W-3D
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WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Infor tion: / WELL ABANDONMENT DETAILS
t
- 7a.Number of wells being abandoned:
Well Contractor Name(or well owner p ovally abandoning well on his/her property) For multiple injection or non-wafer supply ivells ONLY with the some
conslructionlabandonmem,you can submit one form.
NC Well Contractor Certification Number f 7b.Approximate volume of water remaining in well(s): a�S (gal.)
l V�u,� S �U l FOR WATER SUPPLY WELLS ONLY:J '�j
Company Name 7c.Type of disinfectant used: L 1 1 H
2.Well Construction Permit#: , " I O
List all applicable well permits(i.e.County,State,l7ariance,Injection,etc.)ifknovn 7d.Amount of disinfectant used._ �2
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ZIResKential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 4-Co-n—crete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery ,_ @�
Injection Well: 7£For each material selected;aBOKe,proviV"mdnnt.or erials used:
❑Aquifer Recharge ❑Groundwater Remediation
Z �p•� S' � 2 9 n
❑A uiferStora Storage / n ��°��
q g t} ❑Salmtty Barrier
❑Aquifer Test ❑StormwaterDrainage
r •?
❑Experimental Technology ❑Subsidence Control❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the shah bument procedure:
�XCS�dA� ^ / �.��v� AO
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 '�/ /'Ct e'/
( P g) _.)_j
& r
4.Datewell(s)abandoned: LZ Cpy1(✓y p(-P
5a.Well location: _
Gf Q.rr 1V-Ck&" A\1-
Facility/Owner Name J Facility ID#(if applicable) 8.Certificatio
� -alb -V-? 6L.
Physical Address,City,and Zip h� ��7j Signature of ed a ontractor or Well Owner Date
1„,A f t n b��f W��3� �� By signing this form,I hereby certify that the ivell(s)was(here)abandoned in
County _ Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has beer:provided to the well owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) Q 9.Site diagram or additional well details:
3 5 ',by I N Q !� O�Z You may use the back of this page to provide additional well site details or well
y V W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple it jectiou or non-water supply
wells ONLY tritb the same construclionlabm;donmenr,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well Mg: 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 Iniection Wells: In addition to sending the form 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:
s
6d.Water level below ground surface (ft.) Division of Water Resources,Underground Injection Control Program,
7636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): "Q (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
where abandoned.
6f.Inner casing/tubing length(if known): w' (ft)
rp tIl''
IV �
6g.Screen length(if known):_ (ft.)
i
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

••ELtL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
+f^l� �I�+/1 Q✓ 7a.Number of wells being abandoned: /
Well ContractorName(or well ownerpe4onally abandoning well on his/her property) For multiple injection or non-wd,ter supply wells ONLY with /he some
conastruction/abandonment,you can submit one form.
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contrac(toyr�Certificafion Number I l,, ` ' � I
OL p' u-bl i S WSI�>✓1 r 1 l f)-(� FOR WATER SUPPLY WELLS ONLY:
Company Name ! Z �p/ 7c.Type of disinfectant used: H L�
2.Well Construction Permit#l: t J�-� -1 6 nn
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)if known Amount of disinfectant used:
3.Well use(check well use): 'f , .r e tp I H.—La
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPubl®r r 2 2 202 ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) t;Resr�aI Water 4 ly, ngle Cl� e�sd Cement Grout ❑Dry Clay
❑In dustrial/Commercial ❑Residents � ie' tu,Qv�'t�t'0(/ater Suppl)Whr ) ❑ Concrete Grout ❑Drill Cuttings ,
❑Irri ation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry t-B Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected abov ,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 13 t ✓
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
CaA r7 S 6 taw!rh
4.Date well(s)abandoned: .1. O ZL—
Sa.Well location:
C (1 _
`r 8.C 'fica
Facility/Owner Name p Facility ID#(ifa4plicable)
9So n 6-QtAA; e< Q� Q c� l:�wl�-1 e#P YL
Physical Address,City,and Zip Z -z, Signature o ontmctor or Well Owner Date
P4 o n b ( 43 7-. )Z 71- 0 By signing this farm, I hereby certify that the well(s)was(were) abandoned in
County Parcel Identification Now (PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constniction 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 latdong is sufficient) 9.Site diagram or additional well details:
N « � W You may use the back of this page to provide additional well site details or well
(( bb abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well cmtsintciion record(s)if available. For mulliple it jectimr or non-water supply
wells ONLY with lire same constntction!abandmtment,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: Att (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c Borehole diameter: (in.)
above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
e r
6d.Water level below ground surface: 3J (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&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): (fL)
i
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
i