Iredell_Well Abandonment_20230724 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information•l WELL ABANDONMENT DETAILS
r J��'P Y L P`��� 7a.Number of wells being abandoned:
Well Contractor Name(or well owner personaIly abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
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I�)ac__' construclionlabandonmera,you can submit one form. }}��
NC Well Contractor Certification Number \ 7b.Approximate volume of water remaining in well(s): ;t (gal,)
u f 1_S 1 l l/�p FOR WATER SUPPLY WELLS ONLY:
Company Name NZ1��]
�j.�} � 7c.Type of disinfectant used:
2.Well Construction Permit#: S-6l
ist all applicable well permits(i.e.Counry,Slate,Parlance,Injection,etc.)iflotown
7d.Amount of disinfectant used:
3.Well use(checkwell 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) \QBgsidentiaMater Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) oncrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer 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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 3 "` �`'v 5�71 X-1c{y! ' u./`r'
� 4" J eon'ok
4.Date well(s)abandoned: t'
1 V E'
5a.Well location:
(� nn A 2M
yJGtrt)e �- l 0l Y"1-k"\ oi'n'Su -
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: J Unk
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S0114 ( � J. NO-Q14c,0,1� /(�, ��l j7 j lnfior�:a:i� r .- , .
Physical Address,City,and Zip O` Signat Certific Vel on ctor or Well Owner Date
By signing this form,I hereby certify that the ivell(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 154 NCAC 02C.0100 or 2C.0200 Well Constniclion Standards
and that a copy of this record has been provided to the well tnvner.
Jb.Latitude and longitude in degrecc/minutes/cecondc ow decimal degrees:
(ifwell field,one]at/long is sufficient) 9.Site diagram or additional well details:
35, 0-7?49 You may use the back of this page to provide additional well site details or well
N~ W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBNHTTAL INSTRUCTIONS
Attach well construction record(s)if mailable. For multiple iryccrion or non-water supply
wells ONLY with the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
ff _ Division of Water Resources,Information Processing Unit,
6b.Total well depth- 1 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection 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: (fG) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection 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
6f.Inner casing/tubing length(if known): ft) where abandoned_
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013