Iredell_Well Abandonment_20230724 (2)

WELL ABANDONMENT RECORD
For Internal Use ONLY:
L Well Contractor Information: WELL ABANDONMENT DETAILS
Alfred Kiesling Jr •
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 I GW-30 is needed. Indicate TOTAL NUMBER of
3266—A wells abandoned: Q
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): �(� (gal,)
B & K Well Drilling Inc FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorin e
r�f 7c.Type of disinfectant used:
Chlorine
Well Construction Permit#A:�, � ` `qf gl q
List all applicable well construction permits(i.e.UIC.County,State.Variance•etc.)ifknorvn
3.Well use(check well use): 7d.Amount of disinfectant used:
Water Supply Well: 7e.Sealing materials used(check all that apply):
PP Y):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout AB-Sentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) f�Concrete Grout ❑ Drill Cuttings
❑It rriga e
Non-Water ❑Specialty Grout ❑Gravel
r Supply Well:
❑Monitoring ❑Recovery ❑Bentonite Slurry ❑ Other(explain under 7g)
Injection Well: 7f.For each material selected above,provide amn—f nP marl—iced:
❑Aquifer Recharge ❑GroundwaterRemediation Poured & Hydrated
❑Aquifer Storage and Recovery ❑Salinity Barrier / —
❑AquiferTest ❑StormwaterDrainage C'ryl Cd''�C _ /013's's P
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) []Tracer 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) OUt
4.Date well(s)abandoned: 61LEI3
Sa.Well location:
1111 ? 2023
!�—
Facility/Owner Name dtl�t
Facility IDS(if applicable) S.Certification:
Physic Address,City,and Zip Si u e o c 'icd ell Contractor or Wcl wrier Date
By signing this form, I herebv cert ,that the wells) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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:
N �( 1 W You may use the back of this page to provide additional well site details or well
F— abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
Attach well construction record(v)ifavailable. Forrrrrrltiple injection or•non-watersrrpply wells SUBMITTAL INSTRUCTIONS
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 ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
IOb.For Iniection Wells: In addition to sending the form to the address in I Oa
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,) 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 where
6f.Inner casing/tubing length(if known): (g,) abandoned.
6g.Screen length(if known): (g,)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016