Iredell_Well Abandonment_20230828

, WELL ABANDONMENT RECORD For Internal Use ONLY; '
1.Well Contractor Information: WELL ABANDONMENT DETAILS ••
'aj;�� � �����lll��1 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
wells abandoned;
NC ell Contractor Certification Number 7b.Approximate volume of water remaining in well(s): A.?/ (gal.)
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J l ( ./I f31j 5 TX/6 FOR WATER SUPPLY WELLS ONLY:
Company Name i t/J�� i...- 7c.Type of disinfectant used:' ,.. __ f r/
2,Well Construction Permit#: 0.5 WP--YJ� 3-�)-- I4 J
List all applicable well construction permits(i.e.UIC,County State,Variance,etc.)ifknown b7 .
7d.Amount of disinfectant men.._
3.Well use(check well use):
Water Supply Well: 7e.S�Sealing materials used(check all that apply)/::
❑Agricultural ❑Municipal/Public 'Neat Cement Grout 113'lientonite Chips or Pellets
❑G ethermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑Dry Clay
, dtistrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation • ,r-,e—/e°:S'"'y li, IC; d,1 Specialty Grout 0 Gravel
Non-Water Supply Well: rs c.Li L.-iv 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery 2023
Injection Well: AUG7f.For each material selected above,provide amount of mate i Is used:
❑Aquifer Recharge ❑Groundwater Rernediation ,P ` .J, J4/f V I .
❑Aquifer Storage and Recovery ❑Salinit)I1Ba`riie'tit��`ten Pr ; �
qDrainage
p G,�0� ra" I/4 y
❑A trifer Test ❑Stormwater Draina e `
❑Experimental Technology ❑Subsidence Control 7g.Provide a b ief description of the aba donment procedure:
OGeothermal(Closed Loo OTracer 1-/), /JJ j( ��
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) — .. . 1 /v _ _ _ )L/" ]'/4p P15 dJe Pa P�v7
4.Date well(s)abandoned: ✓ -.)
5a.Well location:
1 t -r;
Facili /OviperName Facility ID#(if applicable) 8.Certification: ///,,
94 it 1 l'ier 0/7A43'e51'%/e; itb , ;l�%/�,X:19%'�!a22 8 " ?3
Plsys FAddr ss,City,and Zip Signature of,Certified Well Contractor or Well Owner Date
•yif e:e II By signing this form,I hereby certifythat the well(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.
•513:Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 9.Site diagram or additional well details: •
• 3.l J3I/.23� N 6pf 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 SUBMITTAL INSTRUCTIONS
Attach well canstnrctiodrecord(s)ifavailable.For multiple injection ornon-watersupply wells.
. ONLY with the same construction/abandonment,you can submit one form.
p•
10a. For All Wells: Submit this form within 30 days of completion of well
' 6a.Well ID#: •I A abandonment to the following:
,) Division of Water Resources,Information Processing Unit,
61i:•Total well depth: // c (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b,For Infection 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: ; •
6.d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Servide Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): t (ft.) 10c.For Water Sunnis,&Injection 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 whore
/- abandoned.
6f.Inner casing/tubing length(if known): A! . (ft.)
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6g.Screen length,(if known): /ri (ft.)
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North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
Form OW-30
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