Mecklenburg_Well Abandonment_20230724 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Con ctorr Information: WELL ABANDONMENT DETAILS
S P)2n44V 7a.Number of wells being abandoned:
Well ContractorName(orwell owner pers nally abandoning well on his/her property) For multiple injection or non-ri,ater supply wells ONLY with the same
construction/abandonment,you can submil one form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
ou ff t,u G-5 6 D FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: ` 7
2.Well Construction Permit#: .10ccy 1 : `793
List all applicable well permits(i.e.County,State,irariance,h jection,etc)ifknovn 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement G�Put 0 -T15{Ben tonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ntial Water Supply(single) ❑ Sand Cement Gfo �-EaJ ,Clay
❑industrial/Commercial ❑Residential Water Supply(shared) L.El-C—oncrete Grout J L I I I I 2 4 2023❑Drill Cuttings
❑lrri ation ❑Specialty Grout J ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slu ftP;y*;jV.n j'Jfi.&@, ,WtR"er(explain under 7g)
❑Monitoring ❑Recovery D I KI'MOG
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Z !:j mlls
❑Aquifer Stooge and Recovery ❑Salinity Barrier _T
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer �x / q� &co
o�
❑Geodrermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 1
Sa.Well location: —�
I Lt y 0
Facility/Owner Name Facility IDll(if applicable) $•Certification:
3t�-� 6d e ye �� za -5
Physical Address,City,and Zip (� Signdru<bf Certified W Contm or Well Owner Date
-e G -r / b2 `PZI J By signing this forrn, I hereby curt that the ivell(s)was(ivereJ abandoned in
County Parcel identification No.(PIN) accordatrce ivith I5A NCAC 02C.0.100 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
3 S 1 (�p)� N f30 •7S 4;) W You may use the back of this page to provide additional well site details or well
J abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Allach well construction record(s)if available. For multiple it jection or non-water supply
wells ONLY with the same constrctio labandonnment,you can submil one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: Y" abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 13 Z (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
b above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.)
abandonment to the following:
1 6d.Water level below ground surface: (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (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
6f.Inner casing/tubing length(if known): (ft) where abandoned.
6g.Screen length(if known): t� (ft)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013