Mecklenburg_Well Abandonment_20230602 (6)

1.Well Contractor Information: WELL ABANDONMENT DETAILS -
94 j" �m L/ 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well CO N e(or well owner personally abandoning well on his/her property) well construction/depth,only 1 OW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: ,•
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal,)
/5�"�J �� FOR WATER SUPPLY WELLS O Y•
'Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(I.e.UIC,Coun0%State,Variance,etc.)iflmomat 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaYPublic ❑Neat Cement Grout WBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑IndtistdaUCommercial - ❑Residential Water Supply(shared) ❑ Concrete Grout [3 Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Nonce�-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
lU onitoring ❑Recovery
Irijection Well: 7E For each material selected above,pr vide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation A.1
•.❑Aquifer Storage and Recovery ❑Salinity Barrier
I7A4vtWer Test ❑Stormwater Drainage
❑Er.perimental Technology ❑Subsidence.Control 7g,provide a brief descrip on of the abandonment procedure:
❑Geothermal(Closed Ldop) ❑Tracer /e j„ y2)/i � 7P
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s).abandoned: � `¢-" ......
Sa.Well loc Hon: i J V IN V d 2023
• ep)Y5
S.Cer cation:
Fac,4 /OvinerName Fact' ID#Of applicable)
PP
Physical Address,Ci ,and Zip Signature ofC rtlfied Well Contractor oe Well Owner Date
By signing this form,1 hereby certt)�that the well(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance pith 15A NCAC 02C.0100 or 2C.OZ00 Well Construction Standards
and that a copy of this record has been provided to the well owner.
$b:tatitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlodg issufficient) 9.Site diagram or additional well details:
�� )y /3 p��a You may use the back of this page to provide additiona
N W l well site details or well
9 abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION6ETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well eonstructiolrecord(s)1(avallable.Formultiple infection ornon-wa(ersupply wells
ONLY witb the same cd.struction/abandonmimf,you can submit onejorm. 10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
' 6a:.Well 1D#• •� �
Division of Water Resources,Information Processing Unit,
6b ;'otal well depth:. 3 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b,For In! etion Wells: In addition to sending the form to the address in IOa
above, also submit-one copy of this form within 30 days of completion of well
6c:Borehble diameter: t Gn•) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: / (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
lOc.For Water Sunnly&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): ' (ft•) 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.
6f.Inner casing/tubing length(if known): > (ft)
Ag.Screen length(if known): \
Form GW+30 North Carol\;Department of Environmental Quality-Division of Water Resoyrces
Revised 2-22-2016
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