Iredell_Well Abandonment_20230724

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Inf rmation: WELL ABANDONMENT DETAILS
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a/L IL 7a.Number of wells being abandon�ed:
Well ContractorName(or well o1 er personally abandoning well on his/her property) For multiple injection or non water supply wells ONLY with ilia same
ZconstructioWabandonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume ofwater remaining in well(s): (gal.)
O/v FOR WATER SUPPLY WELLS ONLY: ;
Company Name p 7e.Type of disinfectant used: �i/
2.Well Construction Permit
List all applicable well permits(i.e.County•State,Variance,h jeclion,etc)ifhtown 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) t ential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ncrete Grout ❑Drill Cuttings
❑irri ation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E F9r each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑Groundwater Remediation
❑Aqg R uifer 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 3 / �`X e/�4, G� e�
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g) T Z
4.Date well(s)abandoned:
a.Well location: �✓'
2023
Facility/Owner Name Facility ION(ifapplicable) S.Certification:
Physical Address,City, ( �,and Zip y � �C� Signa Certified Well ctor or Well Owner Date
—T..G't K"9/lu "f�''l� J— 1 By signing this form,I hereby certify that the ivell(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constniction 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 lattlong 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
5 1 N a d uJ W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple h jectimr or nos-water supply
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well Dom: A, abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Infection 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: 4 (in.) abandonment to the following:
6d.Water level below ground surface: ([t) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e Outer casing length(if known): ( IOc.For Water Supply&Injection Wells: In addition to sending the form to
ft) 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
6E Inner casing/tubing length(if known):- (ft) where abandoned.
6g.Screen length(if known): �� (ft)
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Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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