Mecklenburg_Well Abandonment_20230602 (2)

WELD ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.W�e-lll Contractorinff o,/rma'onl / WELL ABANDONMENT DETAILS
" L� -e r 7a.Number of wells being abandoned:
Well ContractorName(orwell owner persona ly abandoning well on his/her property) For muhiple injection or non-i ater supply wells ONLY with the some
construciian/abandonmeni,you can submit one form.
NC Well Contractor Certification Numb l 7b.Approximate volume of water,remaining in well(s):
bL M\AA 4 S f)G' l� FOR WATER SUPPLY WELLS,'ONLY:
Company Name _ 7c.Type of disinfectant used: wtq
�60� 37�
2.Well Construction Permit##:
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)iflmown yy 1'
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
[ Agricultural ❑MunicipaVPublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) estdenti ater Su sin , Clay
. F ��---- ? •di D
Supply g ) �❑ Sand Cement Grau a�.� ,�'a1�e a r
❑industrial/Commercial ❑Residential Water Supply(shared) t76oncrete Grout' ❑Drill Cuttings
❑Irri ation ❑Specialty Grout JUN r 2023❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑9tller(explain under 7g)
❑Monitoring ❑Recovery ��. -<<•}.:,�?;...-.,�^'r'r
Injection Well: 7f.For each ma�61 ia�selecyid, Tjti UMi
k��iPovide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation �,/.y�sj
❑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 '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) �-r� 3 t '/"w 4 o �y/JJ f
C 4 s'4 'IF r}; l+� w.-t4
4.Date well(s)abandoned:L/ 7!73
5a.Well location:
Z
Facility/Owner Name Facility ID#(ifapplicable) $•Certification:
PPhhyssiical dress,City,and Zip - Signatmc of Certified Contractor or Well Owner Date
rt �I.)^ 0/— /S I—lb By signing this form, I hereby certrfy' that the ivell(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.
56.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 - Lf' of C7 5 N 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
Atrach well construction record(s)if available. For multiple b jection or non-water supply
wells ONLY wish the same construction/abandamuent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well M#: 1 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: JOLD (ft.
1617 Mail Service Center,Raleigh,NC 27699-1617
IOb.For Injection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter: �b (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
r 'l
6d.Water level below ground surface _ 30 (ft) Division of Water Resources,Underground Injection Control Program,
��p 1636 Mail Service Center,Raleigh,NC 27699-1636
6e Outer casing length(if known): �(' (fh) 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 health department of the county
6f.Inner casing/tubing length(if known): (ft) where abandoned. '
6g.Screen length(if known): (ft.) i
Form GW-30 North Carolina Department ofEnvironment and Natural Resources—Division of Water Resources Revised August 2013