Mecklenburg_Well Abandonment_20230227

- WELL ABANDONMENTRECOR — , • -.
Fol•Irricinal Uski,ONLYf
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1 Well Coritrutor hifoirnation, .WELL ABAN D()ISISI ENT.DETAI IS
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1 1

6 ,
WELL ABANDONMENT RECORD For Internal Use ONLY: i
1
I ,
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Mike Tynan 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
2725-A -',�;__ `. u"r) - wells abandoned:
7b.Approximate volume of water remainingin well(s):
NC Well Contractor Certification Number pP ! I — (gal.)
I ET FEB 2 1023 FOR WATER SUPPLY WELLS ONLY: •
i.
Company Name �n.•.o
1nfouca,i,,1 pf`-"'J�'1F 3 Uri% 7c.Type of disinfectant used: 1
2.Well Construction Permit#: rJ+f;QM� I,,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if
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 0 Neat Cement Grout II Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial 0 Residential Water Supply(shared) a Concrete Grout r 0 Drill Cuttings
❑Irrigation • 0 Specialty Grout 1 0 Gravel
. Non-Water Supply Well: 0 Bentonite Slurry _ - _ 1 . ❑Other(explain under 7g)
—2JY /Monitoring - ❑Recovery _ _ _ _
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete -'40 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Hole Plug —25 lbs
❑Experimental Technology 0 Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Filled well with bentonite and concrete grout to
surface.
4.Date well(s)abandoned: 02/13/23
Sa.Well location:
Former UPS Freight
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
5204 N. Graham St, Charlotte 28269 ? 2/13/23
Physical Address,City,and Zip Signature of Ce . ed 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.281972 N -80.801986 Kr 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)ifavailable.For multiple injection or non-water supply wells
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#: M W 2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 25 (ft)
li
10b.For Injection Wells: In addition to sending the form to the address in 10a
8.5 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) i,
abandonment to the following:
6d.Water level below ground surface: 3.5 (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 I health department of the county where
6f.Inner casing/tubing length(if known): 15 (ft) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

fl
I
WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
I '
Mike Tynan 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
2725-A wells abandoned: i; 1
NC Well Contractor Certification Number �, lb.Approximate volume of water remaining in well(s): —2 (gal.)
I ET • r -._-,. ;,4.� s
i 'r.",y I'�1 ' FOR WATER SUPPLY WELLS ONLY:
Company Name + ' "`�'�P 9 I 1023 7c.Type of disinfectant used: '
2.Well Construction Permit#: F a -r
t
List all applicable well construction permits(i.e.UIC,County.State,,,,Yasjian eat St lmown
r;..�?i�r ' '1 7d.Amount of disinfectant used:
3.Well use(check well use): 1nt i. -a��V„1 6,°a..
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mtnticipal/Public 0 Neat Cement Grout N Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) P Concrete Grout 0 Drill Cuttings
0 Irrigation 0 Specialty Grout r 0 Gravel
Non-Water Supply Well: _ _ _ O Bentonite Shiny _ _ _ 0 Other(explain under 7g)
!Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete -60 lbs
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Hole Plug -25 lbs
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
['Geothermal(Closed Loop) OTracer Filled well with bentonite and concrete grout to
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
surface.
4.Date well(s)abandoned: 02/13/23
5a.Well location:
Former UPS Freight
Facility/Owner Name Facility ID#(if applicable) 8.Certification: I'
5204 N. Graham St, Charlotte 28269 I 2/13/23
Physical Address,City,and Zip Signature of C/r...a4z,
Well Contractor or Well Owner Date
Mecklenburg By signing this form, I hereby certifylthat the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has bee nprovided 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 deta
ffi ails:
35.2813904 N -80.8009739 �, 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 injection or non-water supply wells
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#: M W 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25 (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: 8.5 (in.)
above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: 1.
I' '
11 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft)
1636 Mail Service Center,Raleigh,NC 27699-1636
I
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Infection 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 comity 1 health department of the county where
6E Inner casing/tubing length(if known): 20 (ft,) abandoned. I
6g.Screen length(if known): 5 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

1.Vy Co it ctar Info an:it)
/ I1 J WELL ABANDONMENT DETAILS';
[/ 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
owner ersonall abandoningwell on his/her property) well construction/depth,only I OW 30 is needed. Indicate TOTAL NUMBER of
Wella??),Ps A p Contractor (or wn P Y wells abandoned:
• •
,;;:77: r : r ° ' •^f 37b.Approximate volume of water I remaining in well(s): , 90 (gaL)
NC Well traror aril learn:miler �5 �'`" �` is11�•� �' / 2 7 2 f 3 FOR WATER SUPPLY WELLS®i Y:
'Company Name 7c,Type of disinfectant used:
ffilirs;;fcr,iDn Prznzcc sg Unit
2,Well Construction Permit#: r^;fietl ro
• ^~ ` ®Z
•
List all applicable well corrstructtorr yarn(is(de.UIC,County State,Variance,etc)fflmonm 7
7d.Amount of disinfectant used:{'
3.Well use(check well use): !,
Water Supply Well: • 7e.Sealing materials used(check all,that apply):
DAgrieultural CMunicipallPublic 0 Neat Cement Grout Cl Bentonite Chips or Pellets
DGeothermal(Heating/Cooling Supply) iDResidential Water Supply(single) Cl SBA Cement Grout O Dry Clay
Oln:histriai/Commercial °Residential Water Supply(shared) etoncrete Grout O Drill Cuttings
°Irrigation • Cl Specialty Grout O Gravel
•
Noryater Supply Well: • Cl Bentonite Slurry 0 Other(explain under 7g)
onitoting• °Recovery •
• IriJection Well: IL For each ma al sale d,above,provide amount of materials used:
DAquifer Recharge °Groundwater Remediation . 6 a i se
f X • 4 d s
•.DAquifer Storage and Recovery °Salinity Barrier
r
DAquifer Test OStormwater Drainage
DBltperimental Technology OSubsidence.Control 7g,Pro de a brief description of the abandonment procedure:
DGeothennal(Closed Ldog) °Tracer i• /?/�y-1i' J D ��f�/,[
°Geothermal(Heating/Cooling Return) DOther(explain under 7g) r f�� � �v j�t/,�� G
4.Date well(s).abandotted: / t '")J t�; • Y J
5a.Well location:
'.. Pill l 11,17
Facility/AHJnerName # Facility #(ifa ca 1e) 8.Ce don: , <..
physical A refs,City,pd Zip • Signature ofG f ed Well Contractor of Well Owner Date
• eo• By signing this form,I hereby cerf(fy that the well(s)was(were)abandoned in
County • Parcel Identification No.(PIN) accordance with 15A NCAC 02C.010D or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
•S▪ hi Latitude and longitude in degrees/minutes/seconds or decimal degrees: li
' (if well field,one iatfodg is sufficient) 9.Site diagram or additional welldetails:
,. .�f1g lv 3 �33 6PP 751�F�_ W You may use the back of this page to provide additional well site details or well
} A _/ tI abandonment details. You may also attach additional pages if necessary.
•CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED EUBAI,INSTRUCTIONS
, Attach well constructio record(s)(favailable,Formulttiplebtleationornao-watersupplywells• •
.ONLY with the same c trstrucfion/abandonm'enf,you can submit one jams Da.For AU Wells: Submit this form within 30 days of completion of well • '•
' 6a;Well Mil: •I • -" abandonment to the following: '
j
Division of Water Resources,Information Processing Unit,
• 6hi:Total well depth:. 4 417 7 (ft.) 1617 Mall Service Center,•Raleigh,NC 27699-1617
• lob.For Injection Wells: In addition to sending the fomr to the address in 10a
•
above,also submit•one copy of this form within 30 days of completion of well
6 Bbrehole diameter: (in.) abandonment to the following: I •
Division of Water Resources,,Underground Injection Control Program,.
6ti.Water level below ground surface: (ft.) 1636 Malt Servt i e i enter,Raleigh,NC 27699-1636
• 10c.For Water Sunnly&Infection Wells: In addition to sending the form to the
'de.Outer casing length(if known): (ft.) • 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. !
61.Inner casing/tubing length(if known): yyI (ft.)
.6g.
•
• ..Screen length.(if known): i \ . (ft.)
•
•
Revised 2.22�016
urrn t3W,30 • • • North Carotint:Department of Environmental Quality-Division of Water Resogrces Y
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• 1.`3►ell1Co tr ct�riInformatio : WELL ABANDONMENT DETAILS
• �iy (�i��, 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Co ctor Name(or well o personally abandoning well on Ms/her property) well constnctionldepth,only 1 OW-30 is needed. Indicate TOTAL NUMBER of
walls abandoned: •
ad-2-2--P ,7-0,, ,,,,,
14m,- s s-''a • aL
"` �-^-} fir .,-w�7Ti.Approximate volume of water remaining in well(s): ( �� (gal.)
NC Cop cactgr C 1�on N el L V
!/ (/ G // /�^�J /� B 2 7 2023 FOR WATER SUPPLY WELLS ONLY:
'Company Name •\
i n L.ta r i t �; 3� ;c;�U r Vic.Type of disinfectant used:
#y). C'wa'Qi�s�%
2.Well Construction Permit#: �!
List all applicable well cottstrttctiott permits(i.e.U/C,County State,Variance,etc.)(l7atown 7d.Amount of disinfectant used:h
, c
..
3.Well use(check well use): l'
Water Supply Well: • 7e.Sealing materials used(check all that app
°Agricultural °MunicipalPublic 0 Neat Cement Grout IIentonite Chips or Pellets
°Geothermal(HeatinglCooling Supply) °Residential Water Supply(single) °Sand Cement Grout I 0 Dry Clay
•
iIndtistirial/Commercial . °Residential Water Supply(shared) °Concrete Grout I, CIDrill Cuttings
°Irrigation ' ' • Cl Specialty Grout 1 CI Gravel •
Non;Water Supply Well: Cl Bentonite Slurry ClI; ' Other(explain under 7g)
Oldonitoring• °Recovery •
&
Injection Well: If.For each mate al s erected aboe,provide amount of materials used:
°Aquifer Recharge °Groundwater Remediation • .l i9 ,) G l4.°Aquifer Storage and Recovery °Salinity Barrier /7iJJJy
;j '• ,
o Aquiifer Test ❑Stormwater Drainage
C)Blclrerimental Technology °Subsidence.Control 7g,provide a brief desgrfption of the abandonment pr edure•
IJ
°Geothermal(Closed Ldop) °Tracer ) R-)/ y f iQiii e V'&7:5
o Geothermal(Heating/Cooling Return) °Other(explain under 7g) i-P s v C "C/
e
4.Date well(s)•abandoued: ) 13—gg
Sa.Well locatio�np- �j
[• 13J' i f/ -ei cp,/v5f
Facility/.OvinerNome8.Certifica on: J/J�
• �45 *MT 'P)i Facit P applicable)Ip 6-Th _ /!� , j�J3 gR.
Phy▪ sical ,City,an Zip Signature of Cetb�ll Contractor or.Well Owner Date
• By signing this form,I hereby der*that the well(s)was(were)abandoned In
:County Paicel IdentiicatlonNo.(PIN) accordance with ISA NCAC 02C.0100 or 2C A200 Well Construction Standards
•
and that a copy of this record has been provided to the well owner.
•S• li:Latitude and loftgitude in degreeslminuteslseconds or decimal degrees: I, ;
• Often field.one lat/lodg is sufficient) 9.Site diagram or additional Well details:
PPS f i 7 You may use the back of this page to provide additional well site details or well
�;3 D i9 c. �1 lei v �'i' abandonment details. You may also attach additional pages if necessary.
•
•CONSTRUCTION'DETAILS OF WELL(S)BEING ABANDONED pUBIVIITTAL INSTRUCTIONS
• Attach well constructiot{record(s)(favailable:Far multiple Infection ornon-Watersupplyink it
ONLY with the same cohstrucUon/abandonment,you can submit oneform. 10a.For All Wells: Submit this fonn within 30 days of completion of well
i ! t abandonment to the following:
• 6a:Well)iD#: •
• • • Division of Water Resources,Information Processing Unit,
: J 4 1617 Mail Service Center,Raleigh,NC 27699-1617
• G6:Total well depth:. Q�7 (ft.)
10b.For Infection 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
`6cl Barehble diameter: (in.) abandonment to the following: I • ,
Division of Water Resources,Underground Injection Control Program,
Gd.Water level below ground surface: ( ) 1636 Mail Service itenter,Raleigh,NC 27699-1636
•
• 10a for Water Snuniv&Infection Wells: In addition to sending the form to the
6e.Outer casing length(if i mown): (ft.) address(es)above,also submitne copy of this form in 30 days
the of
completion
of Well abandonment to the.'c i unity health department
where
•
abandoned.
6f.Inner easing/tubing length(if known): —(ft•)
.6g..Screen length;(if known): 31911 — IQ• •
• (ft.)
•
'• . GW,30 North Carob Department of Environmental Quality-Division of Water Resources
pe�risedaz2-xme
Form .

c
s f u • I .
WELL ABANDONMENT DETAILS
1.Well�ontractar Information: B 1, 1
• t &17/ l/ 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
,�or well ovine wally abandoningl well on his/her property)247 --1' .
well construction/depth,only 1 GW 30 is needed. Indicate TOTAL NUMBER of
Well Con crorN�fne( peY �• I, I
—
wells abandon
,�` — 9b.Approximate volume of water remaining in well(s):_-t________(gal
NC Wel a rC�erdficatioaNumber � o r � ,
• g/°_f Iti 15 12�- , 2 FOR WATER SUPPLY WELLS ONLY:
c� r 2 7r Ij i SiV-
7c.
Comps ame �' 1 3 Type of disinfectant used: II
{(ii�i:ver^,il�rl i,i."`.•�?r��Cri:::7 l✓::1
.\
2.Well Construction Permit#: ,,,, �
List all applicable well construction penults(I.e.UIC,Cotntty.State,Vakairce.�slu�)Jjknoavt 7d.Amount of disinfectant used:1.
•
3.Well use(check well use):
•
Water Supply Well: 7e.Sealing materials used(check all that apply):
[]Agricultural ['MunicipalPublic ' 0 Neat Cement Grout entonite Chips or Pellets
OGeothemral(Heating/Cooling Supply) ' ['Residential Water Supply(single) 0 Sand Cement Grout I, O Dry Clay
OIndtistrial/Commercial ['Residential Water Supply(shared) ['Concrete Grout Cl Drill Cuttings
['irrigation • O Specialty Grout j . 0 Gravel •
Nonsfer Supply Well: 0 Bentonite Slurry Cl Other(explain under 7g)
Ilgonitoring• ['Recovery
• 'Meador:Well: 7E For ea materialsepted above,provide amount� ate r used:
['Aquifer Recharge ['Groundwater Remediation . y,jj,�� le `J-�rq
..['Aquifer Storage and Recovery OSalinity Barrier
['Aquifer Test °Stormwater Drainage
CBxperimentajTechnology °Subsidence•Control I'
7g.Prov_id, �cpt don ofp jnaadonment ptoced r
['Geothermal(Closed Ldop) ['Tracer •
C//��7t /!p� .1)e 1/ 3
['Geothermal(Heating/Cooling Return) °Other(explain under 7g) • -p ,34P fig"
�t
4.Date well(s).abandoned: / d - r1 5a.WI• do;/a'hL •1 c
•: 6Yll c
�/d(b . . •
..
Facility//O nerrNalmmee / /� -.•
Facia IDf(if applicable) 8.Ce tlon: /
•
Physi ddress.City. nd Zip ignature of Corti d Well Contractor or Well Owner Date
�/a/'�� •By signing this form.I hereby cert(jy that the well(s)was(were)abandoned In
:County Parcel IdentlftcadonNo.(PIN) accordance with 1SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
_ and that a copy Olds record has been provided to the well owner.
•Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: II
(▪ if well field,one latAodg is sufficient) 9.Site diagram or additional well details:
• ..3 5'D?R4559 N /l),ellf i 7 You may use the back of this page to provide additional well site details or well
. W abandonment details. You may also attach additional pages if necessary.
s . •
•
•CONSTRUCTIONIDETAILS OF WELL(S)BEING ABANDONED �Ug •AI,INSTRUCTIOII I
• Attach well constracttor(record(s)(avallable.Farmtditpie Infection ornon-watersappty wells,
••par with file fame cdjrstructton/abandonment you can submit onejornr. 10a.For All Wells: Submit'this form within 30 days of completion of well
• 6a.Well MN: i •I 'D • abandonment to the following:i!
• Division of Water Resources,Information Processing Unit,
_ • 1617 Mail Service Center,Raleigh,NC 27699-1617
6b:Total well depth:. (ft.) '
10b.For Infection Wells: Injaddition to sending the form to the address in 10a`.,
•
above,also submit'one copy of this form within 30 days of completion of well J
16c:Biarehhle diameter: am) above,
to the following:; • .
Diviston of Water Itesour I es;Underground Injection Control PMogram,
Gd.Water level below ground surface: I (ft.) 1636 Mail Service'Center,Raleigh,NC 27699 1636.
10c.For Water Sunnly&Infeection Wells:In addition to sending the form to the
▪6e.Outer casing length(if known): ( ) address(es)above,also submit one copy of this form within 30 days of completion
• • of well abandonment to th' county health department of the county where
' abandoned.
6f.Inner casing/tubing length(if known):` (ft.)
.6 .Screen length,(if latown): AJ ' •
S (ft.)
— Revised�22 2016
• • NorlhCanlindDepArtmentof Environmental Quality-Division of WaterResogrces
"pm
—,. .

I; 1
•
• Pf P ,; • I ' 1
1.Wei ontracto I for a•on: e WELL ABANDONMENT DETAILS -
�'� �-1 5 3e11i 1i
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor me(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW 0 is needed. Indicate TOTAL NUMBER of
pi; /�i/�/ p 19 p 7-1.,1_ ^ .L wells abandoned:
6� y c rM1�... '.s+'li:v 5--ki yo , )
NC Well newtor Certification plumber _ —'7b:Approximate volume of wateremaiiiing in well(s): (- (gal.)
C•./' 6 -)) 0/p5 J #C .B 2 7 2023 FOR WATER SUPPLYWEI,LSbNLn ix
Company Name {n.,ra i n Prr c ys,,sr� �12 f1'ype of disinfectant used:
�l i;;�eQ:'1�,OG
2,Well Construction Permit#: s' • I 1; v%j�/
List all applicable well construction permits(i.e.WC Counry.,State,Variance,etc.)flmoxat 7d.Amount of disinfectant used:
•
3.Well use(check well use): I
Water Supply Well: 7e.Sealing materials used(check all that apply):
DAgricultural OMunicipaUPublic CI Neat Cement Grout ntonite Chips or Pellets
oGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) D Sand Cement Grout D Dry Clay
DIndtist ial/Commercial °Residential Water Supply(shared) CI Concrete Grout CI Drill Cuttings
❑Irriga ❑Specialty Grout ji CIGravel -
No ater Supply Well: • CIBentonite Slurry t.;, CI (explain under 7g)
onitoring• °Recovery • I'
injection Well: 7£For each material selected above,provide amount of materials used:
DAquifer Recharge DGroundwater Remediation ,�I/)LO J J I 3 hPq
•.°Aquifer Storage and Recovery °Salinity Barrier f/, 1.
oAiluifer Test OStormwater Drainage
DBxperimenta)Technology OSubsidence.Control II
7g.Provide a brief description of t'e abandonment procedure:
DGeothermal(Closed Ldop) °Tracer /i y, y ��//J g�n procedure:.
OGeoth_ermal(Heating/Cooling Return) °Other(explain under 7g) (�/�/ C�/'a l //„ vv / vG
T
4.Date well(s).abandoned: g •
Sa. . ll location:
•:B 1 Me epj '
Facility/OvkerName ac I v`Tr itylD fapplicable) 8.Certific on: I ,'
• •. . `15 5 Mr) 1pp poll, �I 1o?a3 0
Physical ,s,City,a ip Signature of Ce�ell Contractor of Welt Owner Date
By signing this form,I hereby'cert tha!the weU(s)was(were)abandoned to
•County Paicel IdentificationNo.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
•
and that a copy of this record has;been provided to the well owner.
•5▪ 1i:Latitude and longitude in degrees/minutes/seconds or decimal degrees:
' (if well field,one lat/lori is sufficient) 19 9.Site diagram or additional will details: '
• •:a�co •7 y is-% �p le9j- J 7 W You may use the back of this page,to provide on well sited Is or well
7 O� v c Y+ abandonment details. You mayalso attach additional pagesif necessary.
•CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCCION§
▪ Attach wel1constructlo record(s)i(favatlable.Formuitiple Ideation ornon•water supply well¢ i •
per with she fame cdjuinmtion/abandonment,•you can submit°Want:. 10a. For All Wells: Submit this form within 30 days of completion of well
. 6a.Well ID#: . •13 abandonment to the following: i 1
•
•
. Division of Water Resources,Information Processing Unit,
• 1617 Mail Service Center,Raleigh,NC 27699-1617
▪ 61a:Total well depth:. (ft.) i
• • 10b.For Injection Wells: In addition to sending the form to the address in l0a
•
6ci Bbrehble diameter: t ' (in,) .above,also submit•one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level belowground surface: ij (ft.) Division of Water Resources,Underground Injection Control Program,.
1636 Mail Servicie Center,Raleigh,NC 27699-1636
6e.Outer casinglength(if (ft.)
10c.For Water Supply&!Ideation Wells: In addition to sending the form to the
• known); 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 imown): ' ' ; 4 (ft.) •
' form OW,30 •North Caroni pepartment of Environmental Quality-Division of Water Resogrcl
Revised 2-22 2016
.
;1 . •