Iredell_Well Abandonment_20230515

WELL.ABANDONMENT RECORD r
IntemalUseONLY:
This form can be used for single or multiple wells
II '
1. Mractor�f Information: / WELL ABANDONMENT DETAU�I
9/✓t �l '^G� 7n.Number of wells being abaudoned:
;wall Controetor Name((r owner personally abandoning well on his/her property) For multiple Injection or non-water supply wells ONLY with the same
eonstrucrloNabandonmem,you can submit one form.
1
'lb.Approximate volume of water remaining in well(s): (gal.)
NC ell Contractor Certification Number al.
l
M I X C FOR WATER SUPPLY WELLS ONLY: C E tA
Company Name 7c:Type of disinfectant used:__ Y"/TA.�
3.Well Construction Permit 0: 4 f-Q " 33 0 6 7t— ~1 ` 202
List all applicable well construction permits(i.e.County.State,Variance,etc.)If knowm
7d.Amount of disinfectant used: (y af&- 7"7 �n
1 Well use(check well use):
u_�c
Water Supply Well: 7e.Sealing materials used(iheck all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout JR01rentonite Chips or Pellets LH
❑Geothermal(Heating/Cooling Supply) 'iesidenlial Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay T
❑Industrial/Commercial ❑Residential Water Supply(shared) 'Concrete Grout ❑Drill Cuttings
❑lrri ation ❑Specialty Grout 'ITT-ravel
Non-Water Supply Well: erBentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7r.'For each material selected above,provide amount of materials used: U
❑Aquifer Recharge, ❑Groundwater Remediation Dt
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description o!the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
CGeothermal(Heatin Cooling Return) 00thdr(explain under 7 �re V� /P LI WV II C��i nt(,{—Q lyj/��f -A/)Al CC
_ . oJ1 .�iUt^�e�J '/�Pdi'�': ems, r 74GO�t C1�7 e r'� l
ura� a 3
4.Date tirell(s)'abandoned: _
/n5a.Well location:
Facility/Owner Name Facility IDB(ifappliceble) S.Certification:
Sd `p_ ,yp� ram,
�l( f If��.CMr7 i9 flWV � Lw.""I ,I IL
Physical Address,City,and Zip atA,�t3 Signature of Certified Well Contractor or Well Owner Bate J
By signing this form,I hereby cerr�that the ivell(s) tiros (were) abandoned in
County Parcel identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0100 Well Construellon Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of fhis record has been provided.to the well owner.
(ifwell field,one Ia(Aong is sufficient) 9.Site diagram or additional well details:
3 G s DT o N ��r�ST I I 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.
CONSTRUCTION DETAILS OF WEL (51 R>iNr ABANDONED SUBMITTAL INS TRUCi IONS
Attach well construction records)if avollable, For multiple injection or non-water supply.
wells ONLY with the some constraetion/abandonment,you can submit'oneform. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well IDN:
abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Xotal well depth: J (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole'diamelert (In,) above,also submit one copy of this form•within 30 days of completion of well
abandonment to the following:
6t):1Yaler level below ground surface: �(� (rt.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer'casing length or known): �`-' (it) 10c.for Water Supply&Inieclion 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
6f.Iwner casing/lubing length(if known): (fl) where abandoned. c
fig.Screen length(if knorvn):
Form GW-30 North Carolina Depanment ofEnvbonrnent and Natural Resources—Division of Water all
• - Q° tY Revised March 2013