Mecklenburg_Well Abandonment_20230706 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contract I)formation: WELL ABANDONMENT DETAILS
t 4 lie /�j 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(orwell-awner personally Z.aonmg wc,a on his/her property) well construction/depth,only 1 GW I30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certifi Number 7b.Approximate volume of water remaining in well(s):
FOR WATER SUPPLY WELLS ONLY:
Company Name Q 7c.Type of disinfectant used:
2.Well Construction Permit#: ��� Y 0 0
List all applicable well construction permits(i.e.UIC Counry,State,Variance,etc.)iflatown
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 ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ SS Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 27 Concrete Grout ❑Drill Cuttings
OIrrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other axplain un`de ig�•`.5 r ..�
❑Monitoring ❑Recovery 's
Injection Well: 7£For each material selected above,provide amount of terials usedtl
❑Aquifer Recharge ❑GroundwaterRemediation `� 2023
a e
❑Aquifer Storage and Recovery._ []Salinity Barrier
❑Aquifer Test ❑Stotmwater 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 7 ) O it I u J w
a�la _a
4.Date well(s)abandoned:
5a.Well location:
Facility/Owner Name Facility ID#(if applicable) $.Certification:
Physical Address,City,and Zip Signature Ce Tied Well Contractor or Well Owner t
By signing this form, I hereby certify that the well(s)was (were)abandoned in
County Parcel 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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well d tails:
N W You may use the back of this page t17s"ide 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 wellconstructionrecord(s)ifayadable.For multiple injection ornon-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
A 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:/��ff abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
U 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
6e.Outer casing length(if known): (ft) loc.For Water Suoaly&Infection Wells: In addition to sending theJf rm 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
6E Inner casing/tubing length(if known): ( (ft) abandoned.
6g.Screen length(if known): 11,119A 4 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016