Mecklenburg_Well Abandonment_20230724 (2)

WELL ABANDONMENT R r,l..®d®.lJ For Internal Use ONLY:
This form can be used for single or multiple wells
1.Welj, ontr ac for Ipf �tion: WELL ABANDONMENT DETAILS —�
7a.Number of wells being aband I ned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with fire same
1 coustrnction/abandonment,you can sulu i l one form.
5 7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
E)C, \ i t IAyk�5 V,f )���Q, FOR WATER SUPPLY WELLS ONLY:: /�]
Company Name (� 7e.Type of disinfectant used: /�! l r
2.Well Construction Permit##: ''u l 1
List all applicable ivell permits(i.e.County,State,Variance,Injection,eta)ifknorvn 7d.Amount of disinfectant used: n� 1
3.Well use(checkwell use):
Water Supply Well: 7e.Sealing materials used(check all that apply).
❑Agricultural � ❑�Municipal/Public ❑Neat Cement o 'ems a ❑,L`�Bentonite Chips orPellets
❑Geothermal(Heating/Cooling Supply) LE11 esidential Water Supply(single) ❑ Sand Cement'ro 6 9.ol ty Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ncrete Grout JUL2023 ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite SJIy(p?y terl Procosalf,tg ether(explain under 7g)
❑Monitoring ❑Recovery D+`ri30G
Injection Well: 7E Fqr 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: n❑Geothermal(Closed Loop) ❑Tracer 3 1 {�„f /,� V-Ft^
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned:
5a.Well location:
6fa yl4on S�.e I,t t1lC[
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
3o�Sc4e 'da � �t ��zLe)5 s/a�lz3
Physical Address,City,and Zip Signature of Cerdcd W tractor or Well Owner Date
02,9. 0,1--ty
/ 'l'e L zI h� (� By signing this form, I hereby certify that the ivell(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 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 latllong is sufficient) 9.Site diagram or additional well details:
S .3 t0 % N � .7 3�o Z W You may use the back of this page to provide 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 well construction record(s)if available. For multiple it jection or non-water supply
wells ONLY rvilir the same emtvirtcliordabandoirnrerr{you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDl#: ►A/l� abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: l os (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: (in•) abandonment to the following:
6d.Water level below ground surface 3 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
N) 10c.For Water Supply&Infection Wells: In addition to sending the form to
6e Outer casing length(if known):�T (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
6C Inner casing/tubing length(if known): (ft) where abandoned.
6g.Screen length(if known): N (ft:)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013