Cabarrus_Well Abandonment_20230406

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
�'e++ S fy)Q S�`(1 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
q5 V C wells abandoned:'
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): < (gal.)
Morgan Well & Pump, I N C FOR WATER SUPPLY WELLS ONLY:
Company Name granulated chlorine
/�11/� �A� Z�Z 3^��D� 7c.Type of disinfectant used:
2.Well Construction Permit#:l.. PI!"l� v��r
List all applicable well construction permits(i.e.UIC,Count)t State,Variance,etc)ifknown 3 6 2-
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Ae icultmal ❑Municipal/Public ❑Neat Cement Grout XBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) *esidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundj Ter 9;ineaiation a„- bGAI$ 19tri 0 r;%
El Aquifer Storage and Recovery ❑Salinity Barridi�
❑Aquifer Test ❑Stormwater D g-J C 2023
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer+a2 `' `r r 3 Jj�Provide a bri description of the abandonment procedure: pp
•tuj'*�;'�;� ( 2 ►PC �ro w c t C o�ll cle
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned. 0 L� o�� & c)f bets+ )f ae
Sa.Well location: o^cl ny Ac t 1}� -
Facility/Owner Name Facility M#(if applicable) 8.Certif�WellContactor
z4 3 6 D AX 14W Y 1 3 C• Ccsnco��d,l� O3— 2'L— Z oz)
Physical pAdddress,City,and Zip Z 80 LS S e of Certified or Well Owner Date •
l'�00kf S By signing this forth, 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
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:
3'5, g� 1J N d ®� ®5 W You may use the back of this page to provide additional well site details or well
`7 �! 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 farm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: /f° abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 19 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:
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
�� 1636 Mail Service Center,Raleigh,NC 27699-1636
/
6e.Outer casing length(if known): F'/ (ft.) 10c.For Water Supply&Injection 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): 6 V (ft.) abandoned.
6g.Screen length(if known): / r ! (ft.)
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