Union_Well Abandonment_20230828

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WELL ABANDONMENT RECORD For Internal Use ONLY:, •',i
This form can be used for single or multiple wells II
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matthew Price b III 7a.Number of wells el abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple itjecti y J/r nun-iJatec supply mills ONLY with the ,same
construction/abandonment, r can snbnur ne form.
4546-A1� 0
7b.Approximate vol ni' ofwaterlre naining in well(s): (gal.)
NC Well Contractor Certification Number 1 I ii 1.
Carolina Well Drilling FOR WATER SUP)'Ly WELLS;ONLY:
Company Name 7c.Type of dlslnfe¢,:Ijused 70 h HTH Chlorine
2.Well Construction Permit#: 23-92
List all applicable well permits tl e.County,State, Variance,Injection,eta)if known � 'i 2 oZ
7d.Amount of disinfectant used;_ .
3.Well use(check well use): i 1 ; ; -
Water Supply Well: 7e.Sealing materials t 45d(check all that apply):
❑Agricultural 'DMunicipal/Public 0 Neat Cement Gro>tt;+ : . IR Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 0 Sand Cement Giniit C 0 Dry Clay
(ihidustiialJComincrcial DRcsidcnual Watcr Supply(shared) 0 Concrete Grout I f I 0 Drill Cuttings
❑Inigation . , 0 Specialty Grout 0 Gravel
Noa-Water Supply Well: 0 Bentonite Slurry 1 0 Other(explain under 7g)
❑Monitoring DRecovery
Injection Well: - 7f.For each materialFt1 lected above,provide amount of materials used:
4'
❑Aquife►RecUutge ❑Groundwater•Remediatioit (13)50.10.Begs; !
❑Aquifer Storage and Reeovery .❑Salinity Barrier l i •
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❑AquiferTest OStormwaterDrainage i; I .
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❑Experimental Technology 0 Subsidence Control 7g.Provide a brief de4cription of the abandonment procedure:
❑Geothermal(Closed Loop) OTraeei Chlorinated well.-Terminated casing at surface.
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)' }7.— *-- A
Completely tilled,t iith bentoriite. r \C iZ tj
'7-21-23
4.Date well(s)abandoned: *4"PVC liner in Wpll not rem'oveable -AUG 1023
5a.Well location: Irt,`;rltraicrrpr:r:rm+a.-t r
Waxhaw Bible Church 1, DIRrrQ/DOG
Facility/Owncr Name Facility tot(itapplicablc) 8•Certi6cation:
6810 Pleasant Grove Rd.Waxhaw 28173 i -"�-- . 7-21-23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Union 06-084-001 H60 By signing this And;I hereby c rtifv that the wells)was (were) abandoned in
County Parcel IdentifrcationNo.(PIN) 'accordance wt?ith„15AiNCAC 02C 0100 or 2C.0200 Well Construction Standards
and that a copy of this recr»ti has den provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(.it'well field,one tat/long'is sufficient) 9.Site diagram Or additional w 11 details:
34.56.360 t30.43.1l35You may use the bnek of this p e to provide additional well site details or well
N W abandonment details: You may a so attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL ,TR ' I
Attach well construction record(s)if available. For multiple injection or nun-water supply II '
welts ONLY with the scone conatrvctio✓nbandoument,you can submit orte form. 10a. For All Wells: Submit this tbrm within 30.days of completion of well
6a WeI11U#: ,abandonrnent;tolthelfollowing:• I
Division'of Water •••otirces,Information Processing Unit,
6b.Total well depot: 105 (ft.) 1617.Ma Servile• Center,Raleigh,NC 27699-1617.
10b.For lniection,Welis: in .ddition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in.) above, also submitIone copy o this form within 30 days of completion of well
abandonment to the following: �
6d.Water level below gonad surface: 44 (ft.) Division yyf ter Resour es,Underground injection Control Program,
g1 '1630 Seryl a Center,Raleigh,NC 27699-1636
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l0c.For Water u r i 1 &In ection Wells: In addition to sending the form to
6e.Outer casing length(if known): N/A (ft) the address(es) glove, also s brit:one copy of this form within 3Q days of
of. completion wc abandonm int;to the county health department of the county
where abandons i
6f.Inner casing/tubing length(if known): N/A (ft
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6g.Screen length(if known): N/A (ft.) jl I
Form OW-30 North Carolina Department of Environment and Natural Resources. )ivision of W ter Resources Revised August 2013
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