Mecklenburg_Well Abandonment_20230602

WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor In/fo�r�mation: WELL ABANDONMENT DETAILS 1
7a.Number of wells being abandoned:
Well Contractor-Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
constructimdabandonmeni,you can submit one form.
3��d�-tom
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 10 (gal,)
G u we'llAl FOR WATER SUPPLY WELLS ONLY:Company Name 7c.Type of disinfectant used: �7 T 1J
2.Well Construction Permit#:__'d�`J� �E!i
List all applicable well permits#e.County,Slate,Yariance,Injection,etc.)if known /
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaL(Public 0? eat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) MRI<dential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
) �w
❑Industrial/Commercial ❑Residential Water Supply I (shared) ❑Concrete Grout �_<,- I 'Cuttings
a t�
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry J U N `j .90 20 2a Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each mato�a��elge4ed$gave„^proYid�athpi)at of materials used:
❑Aquifer Recharge ❑Groundwater Remediation L'r i3 Z.V
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonments procedure: -'
❑Geothermal(Closed Loop) ❑Tracer //„_/f �i�t?5 Gu7 Pr wt%[
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) -
4.Date well(s)abandoned: it'z-
5a.Well location:
Facility/Owner Name Facility lD#(if applicable) 8.Certification:
Physical Address,City,and Zip Z Z Z 77 Signature of Certified Well Contractor or Well Owner Date
.✓z /C?���3 j —Z Z I By signing this form, I hereby certify that the wells)was(tvere)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Constniction Standards
56.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:
7
271!K/ Z N y '90, 6 50 Z W 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
Attach Well construction record(s)if available. For multiple h jection or non-water supply
wells ONLY frith the same coustractioufabandonment,your can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the fort to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
P
6d.Water level below ground surface: Z' (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e Outer casing length(if known): (ft.) 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)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
I

WELL.SQL L ABANDONAMN i RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
r Inf 1 �� l 72.Number of wells being abandoned: I
Well Contractor Name(or well o%vidr personally abandoning well on his/herproperty) For nuth ple injection or non-ii,ater supply ivells ONLY with. lire some
�1 construd/mxtabmrdonmeni,you can sub it aneform:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): / /71
�
V W)5 � ��t l/� (� FOR WATER SUPPLY WELLS ONLY:
�
Company Name v 7c.Type of disinfectant used:
2.Well Construction Permit ft 1�O 3 T o J
List all applicable well permits r e.County,Stale,Trariancc,Injection,at if lorman 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
TM's fCla
❑Geothermal(Heating/Cooling Supply) bResiderttiai Water Supply(single) ❑Shand Cement Grout .nV Try
❑Industrial/Commemial ❑Residential Water Supply(shared) u Concm,but ❑Mal uttings
Mitigation ❑Specialty Grout J U N 9 20,23ave1
Non-Water SupplyWell: ❑Bentonite Slurry ❑Other(explain under 7g)
[Monitoring ❑Recovery 1plt;;;iY y ^i� c .;:3i=: 1"M
Injection Well: 7E For each material selected d%VG,.&6Qe amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Z t�Gj2�s
❑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) ✓�( G/ J'1
A.Date well(s)abandoned: 4-1 l 3 l -2,3
Sa.Well location:
Facility/OmrerName Facility M#(ifapplicable) $•Certification:
5 2$ }4 qC- 2S4 2,3
Physical Address,City,and Zip b Signature of Cc9fi ell Contractor or Well Owner Date
By sighing this farm, I hereby certrfy that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0100 Well Construction Slandar ds
and that a coPy of this record has beer provided to the well miner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one larllong is sufficient) 9.Site diagram or additional well details:
t y You may use the back of this page to provide additional well site details or well
S• 3 Z3_l N 00 �3� W abandonment details. You may also attach additional pages if necessary,
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction relvrd(s)if available. For muddple h jecuou or non-water supply
wells ONLY uvth the same�e11conn�slnuctiatVabandomrent,you car submit ane form. 10a. For All Wells• Submit this form within 30 days of completion of well
6a.Well ID#• �Yf7' abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) 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 fallowing:
e
6d.Water level below ground surface• S (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Oates casing length{if mown): t� (ft) 10c.For Water Supply&Inieetion 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 f(mown):-I_(ft) where abandoned.
(i
6g.Screen length(if known): 00
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013