Mecklenburg_Well Abandonment_20231006 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Con yIglformation: WELL ABANDONMENT•DETAIIS
Oft/fj/ 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well CorName(or well personally abandoning well on his/her property) well consittrction/depth,only' 1 GW-30 is needed Indicate TOTAL NUMBER of
O
wells abandoned: 4�
NC Well cation tit 7b Approximate volume of water remaining in
1
FOR WATER SUPPLY,WELLS ONLY: .
Company Name i I .---
/ u
lc.Type of disinfectant used: (/
2.Well Construction Permit M.
Lint all applicable well constraet/cn pe its�C—%State,Variance,etc)if known qO
7d.Amount of disinfectant used:
3.Well use(check well use)::
Water Supply Well: 7e.Sealing materials used(check all that apply):
OAgricultural ❑Mtm' ""pal/Public ❑Neat Cement Grout '' ❑Bentonite Chips or Pellets
/ �'S
❑Geothermal(Heatutg/Cooling Supply) ®Residential Water Supply(single) ❑S ement Grodtt'^-j Fw+L Z r'Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) S(:oncrete Grout O l+T O ❑Drill Cuttings
01rri "on ❑Specialty Grout OCT 6 2023❑Gravel
Non-Water Supply Well: ❑Bentonite S
❑Monitoring ❑Rec ery �COther(explain under 7g)
Injection Well: v0 vi=L�*a
7£For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier S
❑Aquifer Test- ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop): ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating(Coolin Return)/ ❑Other(explain under 7 ) 1
4.Date well(s)abandoned: �� P
Facility/Owner Name Facility 7)}#(ifapplicable) 8.,Certification: q Q
Physical City,and
Signature of Certified ell Contactor or Mll Owner Date
CO1� Parcel Identification No.(PIN) By signing thus form,1 her, certify that the well(s)was (were)abandoned in
accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes(seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one hat/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 WELL1Sl BEING ABANDONED
Anachwdlconsnvctronreewd(s)lfavailable_Formrdripleinjecoonornon-watersirpplywens S"��FA'INSTRUCTION$ONLY with the same cortstructr ' nmsmt,you can submit one form
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well E)#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) 1617 Matz Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: I,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:
6d Water level below ground surfacer (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Seiviee Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): AIA (fy) lOc For Water Suooly&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
JL
,y of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): "� (h) abandoned.
6g.Screen length(if known): C (h)
Form GW-30 North Carolina Department of eparime Environmental Quality Division of Water Resources
Revised 2-22-2016