Mecklenburg_Well Abandonment_20230724

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Wy1F1 entractor Inf rmation. WELL ABANDONMENT DETAILS
_N 1 � �� 7a.Number ofwells being abandoned.
Well Contractor Name or well owner personally ab doning well on his/her property) For multiple injection or non-crater supply wells ONLY with the same
constntctiontabandonmenl,you can submit one form.
N Well Contractor Certification Number '. \ 7b.Approximate volume of water remaining in well(s): 'N (gal.)
FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Z P)P�5
2.Well Construction Permit#:
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)iflatown 4
7d.Amount of disinfectant used: l r 4l
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural r �`
❑Municipal/Public ❑Neat Cement Grout tv' � �rp$en�onile Chips or Pellets
❑Geothermal(Heating/Cooling Supply) r ential Water Supply(single) ❑ Sand Cement Grout ❑Dii3'Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout J U L 94 A.
2 Trill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry 1nfoP*'7_,,4dr,n Prn-cu w, l h lain under 7g)
❑Monitoring ❑Recovery L�1P+Q;13 G
[OAquifer
njection Well: 7f.For each material selected above,provide a ount of material used:
Aquifer Recharge ❑GroundwaterRemediation Ord �
Stora a and Recove k1 lg ry ❑Salinity Barriere1i 'Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment proced c:
❑Geothermal(Closed Loop) ❑Tracer /)
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under 7g) Lid-
`o� C-7
4.Date well(s)abandoned: -7( S 2
5a.Well location: �
rev' r, eV �w VSu' J 3 S
Facility/Owner Name Facility�IDJ
(ifapplicable) 8•Certitica tio
-VO4L
1ystcalAd ss,CtyandZip o
Z
gnauefCettifie a onttactor or Well Owner Date
By signing this form,I hereby certify that the 1ve11(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 dcRrccs:
(ifwcll field,one lat/long is sufficient) 9.Site diagram or additional well details:
J �17��l�J N b L f _1 You may use the back of this page to provide additional well site details or well
G J 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 jection or non-water supply
wells ONLY with the same constructionlabandonmeni,you can submit one fora,, 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,
6b.Total well depth: N (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.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 1 D (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): � 10c.For Water Sualy&Iniection Wells: In addition to sending the form to
—T (ft.) D 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
6£Inner casing/tubing length(if known):_A&!2 _(ft) where abandoned.
6g.Screen length(if known): aA4
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013