Mecklenburg_Well Abandonment_20230602 (3)

YMLL ABANDONMENT 1 RECORD For Internal Use ONLY.
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDON14fENT DETAILS
1-5
G y4p✓ 72.Number of wells being abandon d:
Well ContractorName(orwell ownerlIersonally abandoning well on his/her property) For multiple injection or non-wafer supply wells ONLY ,vitb the same
Pn consimet/ontabandonmew,you can submit one form
NC Well Contractor Certification Number 7b.Approximate volume of Ovate I remaining in weil(s): �.
g L ,�.� 5 (1 FOR WATER SUPPLY WELLS ONLY:
Company Name �41 7c.Type of disinfectant used: r r�]y
14l
()v (�o 2.Well Construction Permit#: ( 1 -3 l
List all applicable well permits(i.e.County,State,Variance,Injection,etc)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipa/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets.
❑Geothermal(Heating/Cooling Supply) dal Water Supply(single) ❑Sand Cement Gt-u�n;.„ — '"''1 Ct t9 I3r Clay.
❑lndustrial/Commercial ❑Residential Water Supply(shared) ncrete Grout " `a FJrtlI Cuttings
❑Irri ation ❑Specialty Grout JI V tN 2dJ
202` 'Gravel
Non-Water Supply Well: ElBentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
L rt
1nfG_r
Injection Well:
7E For each mat a(selecte de amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑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) �k� �� 3 d� °r C
Sys,(� - '"lt,��
4.Date wells)abandoned: 4 s
�t
58.Well loeati n-
Facility/OwnerNante Fac�i'�.ty ID#(ifapplicable) 8.Certi
99 2$ {��.,aQ,e rsm &'Q-( Udd NC 2�12fo7 ! . zj 13 la
Physical,A-ddrys,City,and Zip (�1(` 7',L'Z^ Signanuz ofC ed W ctor or Well()caner Date
By signing this form, I hereby certify that the wells)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Consiniction 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,s•-5 2a q N -go•33-242 You may use the back of this page to provide additional well site details or well
�f W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Atrach well construction records)if available. For multiple ii jeciian or non-water supply
wells ONLY with the saute,co»strction4abandonment,you can submit one form 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IM: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (fG) 1617 Mail Service Center,Raleigh,NC 276994617
10b.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: (in.) abandonment to the following:
6d.Water level below ground surface: (fL) Division of Water Resources,,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10r-For Water Sunoiv&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): —(it 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.
i
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

WELL A]BANDONME1\1S R r,CORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.We oTtrcto(rinforption: WELL ABANDONMENT DETA
IL'S
b 5 1 72L Number of wells being abandoned:
Well Contractor Name(or well owner pc6lnally abandoning well on his/her property) For multiple injection or non-water supply well ONLY with the same
consiructionfabaudonment,you can sabinit h one form.
y33a C 1 ' . Zc13 )
NC WWerrll Contractor Certification Number 7b.Approximate volume of water remaining in wcH(s): (gal.
FOR WATER SUPPLY WELLS ONLY:
Company Name
II L 7c.Type of disinfectant used: HIP
2.Well Construction Permit �Q 13 0 9
List all applicable well permits(i.e.County,Stale,Pariance,Injection,etc.)ifbratm 7d.Amount of disinfectant used: Z � �
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) water Supply(single) ❑Sand Cement Grot�y b "� .,5Q_-_P_!Clay
ete Grout ' a- 6d ❑-DPll Cuttin s
❑Industrial/Commercial ❑Residential Water Supply(shared) �r �:a.> g
❑lrri ation ❑Specialty Grout J UN 9 ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry .r 2021 Other(explain under 7g)
❑Monitoring ❑Recovery t
7f.For each mate 'al selected° bow ovr$e fiiount of materials used:
Injection Well: �ug'r�
❑Aquifer Recharge ❑Groundwater Remediation l�Z t�oltr�l
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑ xperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ����1� �� �_ /]vim �� /J�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 77 69 6
C Date well(s)abandoned:
So.Well location:
P> 1 LofJ5 PLC,
Facility/Owner Name Fac"ty 09(if applicable) $-Certification:
5co to k k�),J4, c'.l"t i2 �i�, 7D
Physical Address,}Ci_ , d Zip � Signature of C on for or Well Owner Date
V r `� 0� _ By signing this farm, I hereby certify that the lvell(s)was(tivere)abandoned in
County J Parcel IdentificationNo.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0100 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 latilong 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
C'
N �a 0 -—K'33 W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)if available. For multiple h jecifou or non-crater supply
urells ONLY trith the same constructiar/abandonntent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID9: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (fit) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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: (in.) abandonment to the following:
19 P
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (fit) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e Outer casing length(if known): iV lY (it-.) 10c. For Water Supply dr Infection 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(tabing length(if known): lt,41 (it.) where abandoned.
I '
6g.Screen length(if known): (it)
Form GW-30 North Carolina Department of F.nvirriument and Natural Resources—Division of Water Resources Revised August 2013

I
WELL
ABANDONMENT
�D,�A� A7r�RECORD
i'V E'LL+13Dt111.�DONME 1 R r'CORD For Intemal Use ONLY:
This form can be used for single or multiple wells
1.Wen C tractor In mation: WELL ABANDONMENT DETAILS
72.Number of wells being aband Ined:
Well Contractor Name(or well owne4ersomilly abandoning well on his/her property) For multiple injection or non-niater supply wells ONLY with the some
r constructlantabairdanmeni,you can submit ane fornt
tJ
NC Well Contractor Certification Number 7b.Approximate volume of water,remaimug in well(s): l 9�(gal.)
1� 11. Q� �Jb/ V' FOR WATER SUPPLY WELLS ONLY:
L, M�l
Company Name
' n 7c Type of disinfectant used: 7�l ( t
2.Well Construction Permit M. jJ•�� D
List all applicable well permits(i.e.County,State,Pariance,Injection,eta)if,4nown 7d.Amount of disinfectant used: Z I f
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Muricipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) J3RssfttMM Water Supply(single) ❑Sand Cemen frm( ❑Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ncrete Groggut �- B tic y�8,brill Cuttings
❑kri ation ❑Specialty Grout 1 ❑Gravel
JL r'V G d
Non-Water Supply'*'Veil: ❑Bentonite Slurry ` 2023 ❑Other(explain under 7g)
❑Monitoring ❑Recovery f�„
Injection Well: 7E For each material selertetl'al�wrb;'p"?trvw amount of materials used:
❑Aquifer Recharge []Groundwater Remediation
❑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 ��� A1 3 I c,�a�,�j
❑G 1
eothermal(Heating/Cooling Return) ❑Other(explain under 7g) d r
4.Date well(s)abandoned: O
So.Weil location:
Facility/OwnerName Facility ID#(ifapplicable) 8-Certif e.'tion:
3-721 "dailp tic ant (a 70
Physical Address,City,and Zip Sign 'o ed Well Contractor or Well Owner Date
M-'C y` "4 0� By signing this form, I hereby certify' that the well(s)was(we're)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Siandar ds
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:
5"Q�7 3325 ^p ��� 3 W You may use the back of this page to provide additional well site details or well
N O abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL,INSTRUCTIONS
Anach well courstmction record(s)ifavailable. For multiple injection or nan-water supply
wells ONLY with the same co astructionfabandonment,yam can submit one form. 10a. For All Wells• Submit this form within 30 days of completion of well
6a.Well M#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: b (ft) 1617 Mail Service Center,Raleigh,NC 276994617
10b.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
6r:Borehole diameter: (in•) abandonment to the following.
6d.Water level below ground surface 35 (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): A) where abandoned.
I '
6g.Screen length(if known): (ft)
Form GW 30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013