Mecklenburg_Well Abandonment_20230419 (6)

WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
John W. Huneycutt 7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on hisiber property) For multiple injection or non-water: supply wells ONLY with the same
constructionabandonmeni,you can submit ione form
2465-A 187.5
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): (gal.)
Derry's Well Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Granular,
2.Well Construction Permit#l: 10013142
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)ifknmun 7d.Amount.of disinfectant used: 1/2 lb.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) .❑Concrete Grout ❑Drill Cuttings
❑" ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: 21 Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7.E For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑GroundwaterRemediation 600 lbs- Bentonite 50 Ibs-Bentonite Chips
❑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 Well was pump grouted with bentonite slurry through
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
a.1"tremie pipe from bottom to top:
4.Date well(s)abandoned: 6/20/22
5a.Well location:
SM Smith &Sons Inc. APR 1 a 2023
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
1734 Mineral Springs Rd, Charlotte 28262 (,{J �/ -:,1 i -;7/10/22�1 :i
Physical Address,City,and Zip g� .a
Si t fCertified Well Contractor or Wiyowner
Mecklenburg 047-032-07 By signing.this form,I hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accardance 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/secouds or decimal degrees:
(ifwell 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
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 mailable. For multiple injection or non-water supply
wells ONLY wilt the same construction/abandonment,you can submit one form. 10ir. For All Wells: Submit this form within 30 days of completion of well
6a.Well IIJtf abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
66.Total well depth: 145 (ft.)
lob.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: 6 (in.) abandonment to the following:
6d.Water level below ground surface: 20 Division of Water Resources,Underground Injection Control Program,
(B) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer rasing length(if known): (R•) 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.
6E 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 Resources Revised August 2013