Mecklenburg_Well Abandonment_20230905 (3)

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WELL A13AN DUNMJN!'RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
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( rev,-
C 1 5 7a.For Geoprobe/DPT or Cho f d-Loop Geothermal Wells having the same.
Well Contractor Name(or well owner personalty abandoning well on his/her property) well construction/depth,only 1 OW-30 is needed. Indicate TOTAL NUMBER of
q wells abandoned:
NC Well Contractor Certification Number j� 7b.Approximate volume of water remaining in well(s): 37 5 (gal.) .
F ca-v'C; s &e A l d PL/rpi p 67 i FOR WATER SUPPLY WELLS ONLY:
Company Name
/ 7c.Type of disinfectant used: /4 7i
2.Well Construction Permit#: (C)� 1 3qq qp .
List all applicable well construction permits(i.e.UIC,Comity,State,Variance,etc)ifknown 7d.Amount of disinfectant used: I c-i
3.Well use(check well use):
. Water Supply Well: 7e.Sealing materials used(cheek all that apply):
❑Agricultural o�_MMu�unicipal/Public 0 Neat Cement Grout l3'eentonite Chips or Pellets
. OGeothennal(Heating/Cooling Supply) 67itesidential Water Supply(single) 0 Sand Cement Grout ci Dry Clay
❑l ndustrial/Conunercial ❑Residential Water Supply(shared) 0 Concrete Grout P Drill Cuttings
Gllrrigetion ❑Specialty Grout ❑Gravel
_ Non-Water Supply Well: .
°Monitoring-- — - - - - - °Recovery Bentonite Slurry ,__ El Other(explain under 7g)
Injection Well: 7f.For each material selected above,provide amount of materials used:
°Aquifer Recharge ❑Groundwater Remediation 3'70(9 '6 S
• cAquifer Storage and Recovery ['Salinity Barrier
-
°Aquifer Test OStormwater Drainage
ClExperimental Technology cSubsidence Control
❑Geothermal(Closed Loop) °Tracer - 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/CoolingReturn) °Other(explain under 7g) -V1 10 Ui)j tv, i,W-
4.Date well(s)abandoned: 7 Z 5-2.3 ' �,+--�,L.;�V _i
5a.Well location: S t I' 6.20 23
cc.gy g(61.Corimerce PAJ-k
information Prc-zw.vi.g Ur
Facility/OwnerrName . Facility I D#(if applicable) &Certitlea on: D O18-0G.
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Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
` eLK_l t2n 17V t y3"'Z By signing this form, I hereby certt that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NC,4C 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details: • -
N 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 SUBMFITAL INSTRUCTIONS
Attach well conslructionrecord(s)ifarailable.For multiple injection ornon-watersupplywells
ONLY with the swine consinrction/abandonment,you cgn submit one form. 10a.For AIL Wells: Submit this form within 30 days of completion of well
6a.Well ID#: At!et abandonment to the following:
p/ Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1 o v (ft.) - 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameters (in,) above,also submit one copy of this form within 30 days of completion of well
2 abandonment to the following:
6d.Water level below ground surface: 30 (n,) Division of Water Resources,Underground Injection:Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
6e.Outer casing length(if known): ,ir i (ft) 10c.For WatetSunuty&fniection 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 where
6f.Inner casing/tubing length(if known): AlA1A (ft.) abandoned.
6g.Screen length(if known): Jb/Y1 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-tlivieinn of Water Recnnr' na.. .o»1mL