Mecklenburg_Well Abandonment_20231006 (2)

WELL ABANDONMENT RECORD For Imemal Use ONLY: ,
1.Well Con It= WELL ABANDONME NT DETAILS
C 7 I
f
a.For Geoprobe/DPT or'Closed-Loop Geothermal Wells having the same
Well qonva=r Name(orweIl ovtaer persomilIy abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed Indicate TOTAL NUMBER of
6 Y-2 wells abandoned:
NC Well r CertiS Number 7b.Approximate volume of water remaining in well(s): (gal,)
FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit 7c.Type of disinfectant used:
#:. �tJ D�
List all applicable weU construetign permits 0'.e.UIC Corrmry,State,Varimrce,eta)#fb own
3.Well use(check well use):i 7d.Amount•of disinfectant used:
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Man al/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply ❑ i
uPP Y Cement oft. �` Y y 4 Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) Concrete Grout- v� Y_i,f;,_t: @ A�®�Dr511 Cuttings
[Hrrigation
Non-Water Supply Well: ❑Ben om SIuu t O C T 0 b 2023❑Gravel
❑Monitoring ❑Recovery ❑Other(explain under 7g):
Injection Well: t ,rv.`i^•1 �r;,,srti, _ryq i�;'l
7E For each n �iial'se) coed abgy roYide amount of materials used:
[]Aquifer Recharge ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
o�
❑Aquifer Test- ❑Stormwater Drainage
❑Experimertal Technology ❑Subsidence Control
❑Geothermal(Closed Loop); ❑Tracer 7Pr Provide a brief description of the abandonment procedure:
❑Geothermal(Heating(Coolin Return), ❑Other lain under 7 )
4.Date well(s)abandoned:
Sa.W location-
F ty/Owae Name Factflity ID#(7a1p'p'4"Z*)0A-
Physical 8.Certification
d 2 -3 o t�,s AddreCity,and Zip Signature o ed Well Conhactor or Well Owner
Date
G
By signing this form, I hereby certify that the well(s)was (were)abandoned in County Parcel Identification No.(PIN)
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.
(ifweU Sell,one LC/long is sufocrit
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(Cl BEING ABANDONED
AttacbweUc0=&uctronrieewd(s),'available.Formnrldpleimjectionornon-watersupplywems yUB rAL INSTRUCTIONS
ONLPwith the same constructio' nm-1 you can submit one form
108. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDA abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth - ft 1617 Marl Service Center,Ralegh,NC 27699-1617
10b.For Infection Wells:; In addition to sending the form to the address in 10a
6c.Borehole diameter. .2 (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the followin g
6d.Water level below ground surface: (D) Division of Water Resources,Underground Injection Control Program,
"Z&
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):-A� (h) loc.For Water Suaoly&Infection 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
6E Inner !
CASing/tab'tug length(if known): a (ft,) abandoned. ,
6g.Screen length(if known): d 4--r— (fo
Form GW-30 North Carolina Department of Envirormmml Quality-Division of Water Resources
Revised 2-22-2016
i
I ,
I