Mecklenburg_Well Abandonment_20230626 (9)

WELL ABANDONMENT RECORD For Intemai use oNLy:
1.Well Contractor Information:: GG WELL ABANDONMENT DETAILS
/ 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW i 30 is needed. Indicate TOTAL NUMBER of
wells abandoned:+
NC Well Contractor Certification Number 7b.Approximate volume of waterlremaining in well(s): y (gal.)
Morgan Well & Pump, I N C FOR WATER SUPPLY WELLS ONLY:
Company Name granulated chlorine
7c.Type of disinfectant used: g
2.Well Construction Permit#: /60 ' g
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)ifknownn
7d.Amount of disinfectant used: 50�
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that appl7):
❑Agricultural ❑_EEMunicipal/Public ❑Neat Cement Grout CKBentonite Chips or Pellets
i�x❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ❑ Sand Cement Grout ❑Dr31'Clay
❑Indust ial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
01nigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery []Salinity Barrier 5o bS ;r,r „ , S -d }
❑Aquifer Test ❑Stormwater Drainage _
❑Experimental Technology El Subsidence Control
7g.Provide a brief description of the abandonment pprocedure:
❑Geothermal(Closed Loop) ❑Tracer : i
�J / •�� � l,ra
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Balled D��JC S �QN� (�^B /BUG �OC(fi t'UTi;�O0
oF( Cas�nq be/aW/ ��a ./ •V/ sec�Pc�
4.Date wells)abandoned: b 23
6vt /!fICd 1,UA/ &AA7nfC, ,QS , I/lldm
Sa.Well location: �—J "�
,4�1rye/ All e s L.L C ,svcn Eohi�e /
Facility/Owner Name Facility ID#(ifapplicable) 8.Certifie 'on:
�1533 J/Xg/av'2 -- ✓1� /�i"ll f� ///tt�//P l! a 3
Physical Address,City,and Vip
r tune of C ifiedn, �zereby
ntrac r or'Well Owner Date
By sigttittg this for cent that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.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:
�J
2 5 N W C QO r, You may use the back of this page to provide additional well site details or well
O D G_J abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply ivells
ONLY with the same construction/abandonment,you can submit one farm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: Y abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (9 J (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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
6e.Outer easing length(if known): (ft.) 10c.For Water Supply&Injection 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 where
6f.Inner casing/tubing length(if known): X (ft.) abandoned.
I
6g.Screen length(if known):1i (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised•2-22-2016