Mecklenburg_Well Abandonment_20230327 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
I.Nell Contractor Information: WELL ABANDONMENT DETAILS
Gregory Boggs 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
4514-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of wadi remaining in well(s): (gal.)
S&M E, Inc. FOR WATER SUPPLY WELLS ONLY: p^
Company Name ' =
70003120 7c.Type of disinfectant used: +-- .._i .{}
2.Well Construction Permit#: MAR 2 /
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)iflmown 2023
7d.Amount of disinfectant used:
3.Well use(check well use): 771777 .?
Water Supply Well: 7e.Seating 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
❑IndustriaVCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
e Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3/8" Bentonite Pellets 4 bags (200lbs)
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Grout 1 bag
❑Experimental Technology ❑Subsidence Control 7g Pro%ide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Filled with 4 bags of bentonite to approx. 12" from surface.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Topped well off with 12"of grcut and an area approx. 12"X 12"at surface
4.Date wells)abandoned: 2/28/2023
5a.NNell location:
Johnson & Wales University n/a
I'acllllA OVAn2I Name Facility ID#(ifapplicahle) 8.Certifie •On:
713 West Trade Street, Charlotte, 28202 Gi �u ?622
Physical Address,City,and Zip Signan rj'QfCeWed Well Con or or Well Owner Date
Mecklenburg 07315109 By signing this form, I hereby certify that 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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well 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
35.232105 N 80.849251
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#: TM W-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
4 1/4++ 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (ill.) 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: 20.94 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
15 (ft.) 10c.For Water Suooly&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
6f.Inner casing/tubing length(if known): (m) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Envirommental Quality-Division of Water Resources Revised 2-22-2016