Mecklenburg_Well Abandonment_20230602 (5)

1.Well Contractor Information: WELL ABANDONMENT DETAILS -
� �� 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some
L well construction/depth,only I OW-30 is needed. Indicate TOTAL NUMBER of
Well Coonnnactor Name(or well owner personally abandoning well on his/her property)
s� wells abandoned:
s�
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): _(gal.)
FOR WATER SUPPLY WELLS ONL :
'Company Name AM 7c.Type of disinfectant used: Off
2.Well Construction Permit#:
List all applicable well consh7rction permits(t.e.UIC,Counri%State,Variance,etc.)U*knoxat ?d.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 OBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
OlndtistrIal/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
Olrrf ation ❑ Specialty Grout ❑Gravel
No Mater"Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
onitoring ❑Recovery
Injection Well: 7f.F8�nchm7;;selected above, rovide amount of materials used:
OAquifer Recharge ❑Groundwater Remediation
.OAquifer Storage and Recovery ❑Salinity Barrier
OAqu'ifer Test OStormwater Drainage
OExperimental Technology ❑Subsidence.Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Ldop) OTracer
OGeothermal(Heating/Cooling Rehm) ❑Other(explain under 7g)
4.Date well(s)-abandoned:
5 ,T?Vell location: t J O N 2202.1
Facili /Over ame �• F c ity IDN(i applicai S.Certifi a on:
PIP&
Phys Addres�ty,and Zip �+ J ® ,1 Signature ofCetti6ed Well Contractor of Well Owner Date
By signing this form,I hereby certify that the well(s)was (were)abandoned in
County Paicel 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.
Sli:Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well.fi d one lat/lodg is sufficient) y� AP m 9.Site diagram or additional well details:
•. oJ�� - K / �� W You may use the back of this page to provide additional well site details or well
LL abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION lDETAILS OF Wnw)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructiolrecord(s)tfavaflable.For multiple injectionornmo-watersupplywells.
ONLY with the same copstnrctl`o�n/ebandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a:Well WH; abandonment to the following:
' J 1 �j f Division of Water Resources,Information Processing Unit,
6b:Total well depth:. fi (ft.) 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Infection 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 following:
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
length �f known• (ft-) 10c.For Water Supply&Infection Wells: In addition to sending the form to the
6e.Outer casing g ( )• 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
6f.Inner casingltubing length(if known):
abandoned.
.6g.Screen length(if known): �\ (ft.)
:Form GWJ0 North Carol\;Department of Environmental Quality-Division of Water Resogrces Revised 2.22-2016