Mecklenburg_Well Abandonment_20230113

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I
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells f`
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CARL CARPENTER 7a.Number of wells being abandoned:I 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or Harr t ter supply ire//s ONLY with the scrnre
construction/abandonment,you can submit one formr.
A -4475
NC Well Contractor Certification Number 7b.Approximate volume of water",remaining in well(s): 0 5 (gal)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: G
2.Well Construction Permit#: AN
List all applicable well construction permits(i.e.County,State,lrariance,etc.)ifknown r
7d.Amount of disinfectant used: •`
3.Well use(check well use):
7e.Sealing materials used(cheek'all that aPPIY) r1 s . dS- .n'tWater Supply Well:
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips orellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
[Irrigation 0 Specialty Grout ❑ Gravel
Non-Water Supply Well: I?l Bentonite Slurry ❑Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRetmediation 1.0 GALLONS
❑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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned:- 09/19/22
5a.Well location: 7
MITCHELLS FORMAL WEAR
Facility/Owner Name Facility I Dff(if applicable) 8•Certification:
115 SCALEYBARK ROAD CHARLOTTE 28209 C-rn� 09/22/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
MECKLENBURG By signing this form, I hereby certify that the ivell(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.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 lit/long is sufficient) 9.Site diagram or additional well details:
35e 11' 23.51" 800 52' 30.61" 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
Attach well construction recorcl(s)if arailable. For multiple h jection or non-water supply
wells ONLY with the sane constructioniabandoivuent,you can subunit one form 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#: MW-4 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 25.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
1.0 above,also submit one copy of this form within 30 days of completion of well
Gc.Borehole diameter: (in.) abandonment to the following:
10.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
loc. For Water Supply& Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment tb the county health department of the county
6f.Inner casing/tubing length(if known): (ft.) where abandoned. �
i
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water �ali Revised March 2013
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WELL ABANDONMENT RECORD For Internal Use ONLY: l
This form can be used for single or multiple wells I4`
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CARL CARPENTER I I 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For tnulliple it jection or non-i raier supply wells ONLY with the same
construction/abandonment,you can submit one form.
A -4475 ;
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0'S (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name - 7c.Type of disinfectant used: .'ham'
2.Well Construction Permit#: `"��c•_� ,}f t/� .i ')
/.ist all applicable we//constractiar perntitr(i.e.Cotonp,State,Variance,etch)if known 7d.Amount Of disinfectant used:
3.Well use(check well use): -
Water Supply Well: 7e.Scaling materials used(check all that appAV0T;r: 3' ,I
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Cs6tpsOT Pgle�
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: IZI Bentonite Slurry ❑ Other(explain under 7g)
EMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 1.0 GALLONS
❑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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 09/19/22
5a.Well location:
MITCHELLS FORMAL WEAR
Facility/Owner Name Facility ID#(ifapplicable)
8.Certification:
G-r
��G`' C 09/22/22
115 SCALEYBARK ROAD CHARLOTTE 28209 -� 7•" "�`
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
MECKLENBURG By signing this form, I hereby certify that the well(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.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:
350 11' 22.33" N 800 52' 27.34" 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)if available. For multiple it jection or non-water supply
wells ONLYwitb the satue constructiontabandonntent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#: MW-6 abandonment to the following:
Division of Water Quality,Information Processing Unit,
Gb.Total well depth:
25.0 (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: 1.0 (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: 10.0 (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c. For Water Sunrtly& 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
Gf.Inner casing/tubing length(if known): (ft.) where abandoned. Ilf
Gg.Screen length(if known): (ft.)
Forth GW-30 North Carolina Department of Environment and Natural Resources-Division of Water uali Revised March 2013
P QI
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I
I
WELL ABANDONMENT RECORD For Internal Use ONLY: I j
This form can be used for single or multiple wells tft
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CARL CARPENTER I' I 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the sane
A - 4475 construction/abandonment,you can suboi i one fora.
25
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): ' (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name "'fl. ,a `I
7e.Type of disinfectant used: :� f z )
2.Well Construction Permit#: J N C
List all applicable well construction permits(i.e.County.State,Variance,etc.)if known 7d.Amount of disinfectant used:
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) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: El Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 4.25 GALLONS
❑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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain-under 7g)
4.Date well(s)abandoned: 09/19/22
5a.Well location: `
MITCHELLS FORMAL WEAR
Facility/Owner Name Facility 1D#(if applicable) 8•Certification:
115 SCALEYBARK ROAD CHARLOTTE 28209 C--�� �' �
_ 09/22/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
MECKLENBURG By signing this fonn, I hereby certify that the ivell(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 11' 24.35" N 800 52' 24.45" 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.
r
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(y)if available. For multiple b jection or non-water supply
wells ONLY with the sane construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
MW-21 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 26.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2.0 (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
10.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
i
loc. For Water Supply& IniectionI Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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. I
6E Inner casing/tubing length(if known): (ft.) I
6g.Screen length(if known): (ft.) ff
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Form OW-30 North Carolina Department of Environment and Natural Resources—Division of Water Qi ality Revised March 2013
I

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CARL CARPENTER 7a.Number of wells being abandi ni d: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-,ivaler supply wells ONLY with the same
consiructioniabandonment,you can submit one form.
A - 4475 r 3.5
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: ,' • x
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: 1Ii n�v
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: I�'C Jq I y 11 3
3.Well use(check well use): r,l.,,; ^'�•'?.;•,
ri fir,
Water Supply Well: 7e.Sealing materials used(check all that apply): {s
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 21 Bentonite Slurry ❑Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 5.0 GALLONS ;
❑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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 09/19/22
5a.Well location:
MITCHELLS FORMAL WEAR
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
115 SCALEYBARK ROAD CHARLOTTE 28209 G � � -- 09/22/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
MECKLENBURG By signing this form, I hereby certify that the ivell(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.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:
(if well field,one]at/long is sufficient) 9.Site diagram or additional well details:
350 11' 22.93" 800 52' 23.75" 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'
Attach Nell construction record(s)if available. For multiple h jection or non-water supply
wells ONLY with the same catsiruciion/abandomuent,you can submit one jonn• 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-22 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 31.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
Gc.Borehole diameter: Jim) abandonment to the following:
1 Q,Q Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
I
loc.For Water Supply&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit'one copy of this form within 30 days of
completion of well abandonment;to Ithe county health department of the county
where abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources'—Division of Water Quality Revised March 2013

i
WELL-ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CARL CARPENTER 7a.Number of wells being abandon Id: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-%ater supply wells ONLY with the same
construction/abandonment,you can sub Itit pne form.
A - 4475
7b.Approximate volume of water,remaining in well(s): 0.5 (gal.)
NC Well Contractor Certification Number )
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS!ONLY:
Company
P y Name 7c.Type of disinfectant used:
4
2.Well Construction Permit#: JAN 1 2023
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown It
7d.Amount of disinfectant used:;3.Well use(check well use): Un,
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) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel 1
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 1.0_GALLONS
❑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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
El Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 09/19/22
5a:Well location: —
MITCHELLS FORMAL WEAR
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
115 SCALEYBARK ROAD CHARLOTTE 28209 09/22/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
MECKLENBURG By signing this form, l hereby certify that the well(s)was(were) abandoned in
Comity Parcel Identification No.(PIN) accordance with 15A NCAC 02C.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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 11' 21.23" 800 52' 29.02" 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.
Attach well construction record(s)if available. For multiple injection or nor-Crater supply
trel/s 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#: MW-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
25.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
10 above,also submit one copy of this form within 30 days of completion of well
.
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 10.0 (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Sunnly&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit)one copy of this form within 30 days of
completion of well abandonmentitolthe county health department of the county
where abandoned.
6f,Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form G W-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells V i
1.Well Contractor Information: WELL ABANDONMENT DETAIIIS
CARL CARPENTER I 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple hyection or non-water supply hells ONLY with the same
cottsatrctiotvabattdontnett,you can.subntit one form.
A -4475 !
NC Well Contractor Certification Number 7b.Approximate volume of water,'remaining in well(s): 0 5
(gal-)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: /, .�
t7
Company Name 7c.Type of disinfectant used -'.;'
2.Well Construction Permit#: AV j `
List all applicable well construction permits(i.e.County,Stare,Variance,etc.)ifknaum
7d.Amount of disinfectant used::, t,.<_ r
3.Well use check well use): r.,
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) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: El Bentonite Slurry ❑ Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 1.0 GALLONS
❑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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) 00ther(explain under 7g)
4.Date well(s)abandoned: 09/19/22
5a.Well location: - — -
MITCHELLS FORMAL WEAR
Facility/Owner Name Facility ID#(ifapplicable) g•Certification:
115 SCALEYBARK ROAD CHARLOTTE 28209 1-4-�� �� 09/22/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
MECKLENBURG By signing this form, I hereby certh,that the ivell(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 11' 22.44" 80e 52' 26.30" You may use the back of this page to provide additional well site details or well
N NY abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(v)if available. For multiple byection or non-seater supply
wells ONLY with the same constructioniabandownent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• M W-2 abandonment to the following:
Division of Water Quality,Information Processing Unit,
Gb.Total well depth: 25.0 (ft•) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
1.O above,also submit one copy of this form within 30 days of completion of well
Gc.Borehole diameter: (in.) abandonment to the following:
10.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Sunoly&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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): (ft.)
6g.Screen length(if known): (ft.)
i
Form OW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013