Iredell_Well Abandonment_20231024

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WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: J WELL ABANDONMENT DETAILS
4 I (�-r` 7 L .IL I. P Jr 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning w I on his/her property) well construction/depth,only 1 lGW-30 is needed. Indicate TOTAL NUMBER of
7 /{ wells abandoned: / 1 C
V 02 6 to - �'l 76.Approximate volume of�ater remaining in well(s): ( Q (gal.)
NC Well Contractor Certification Number � I. '
+ t 1e (i ���t n �� • FOR WATER SUPPLY WELLS ONLY:
Company Naamc W 6 [[��1 7c.Type of disinfectant used:_ (1k 1 el i ti G
2.Well Construction Permit#: `ao d J— 34 51\ ,
List all applicable well construction permits(i.e.UIC.County.State,Variance.etc.)if known 7d.Amount of disinfectant used: 2 ZCz.. S
3.Well use(check well use): •
Water Supply Well: 7e.Sealing materials used(check all that apply):
ipal/Public 0 Neat Cement Grout cntonite Chips or Pellets
❑Agriculrural ❑MunicI
' ❑Geothermal(Heating/Cooling Supply) (Bltesidential Water Supply(single) 0 Sand Cement Grout II 0 Dry Clay
Olndustrial/Commercial ❑Residential Water Supply(shared) @'Concrete Grout
I. 0 Drill Cuttings
❑ircigation
0 Specialty Grout 0 Gravel
. Non-Water Supply Well: 0 Bentonite Slurry I 0 Other(explain under 7g)
❑Monitoring
❑Recovery I
injection Well: 7f.For each material selected above,provide amount
`of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 3 3 /5 5 / 1e 1 t&'
❑Aquifer Storage and Recovery ❑Salinity Barrier cc), cat-I t,
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief dese ' tion of the abandonmen procedure:
❑Geothermal(Closed Loop) ❑Tracer
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) P�( 2 C J I' n,_) rCa(
4.
4.Date wells)abandoned: t e•ta„•:,,..r r''' ,; '',j a
5a.Well location:
! (�C T 2(pZ3
11 ti'Y\ Yve.\Q Y\ J 0
FacilitylD#(ifapplicable) 8.Certification: I. • In`— ."•'l ,
Facility/Owner Name ^s I)�1 I - U i''I � -
L1' ' \in 1.v\ l '� mresv \1t 7,. . i. _ �y
Signature of Well Contra for or ell Owns to
Physical Address,Ci ,and Zip Si', p � ft�ifiedI
'Ct.a&\,` LI 1 O '0 [05$11 By signing this form, I hereby cent t t the'well(s)was(were)abandoned in
�ounty Parcel identification No.(PiN) accordance with 15A NCAC 02C. 0 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 latrlong is sufficient) . 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N W abandonment details. Youimay also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction recard(.clifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one jnnn. 10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID#:
Division of Water Resources,Information Processing Unit,
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(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.dfotal well depth: 3 I'
10b.For injection Wells: In addition.to sending the form to the address in l0a
above.also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
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�/+� Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: "�/ (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&
6e.Outer casing length(if known): (ft.) 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 t l the county health department of the county where
• 6f.Inner casing/tubing length(if known): (ft.)
abandoned.
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-3 ?016