Mecklenburg_Well Abandonment_20231024 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.We ontractor Information: WELL ABANDONMENT DETAILS
� I
r)S a �� ¢
r 7a Number ofwells being abandoned: I
Well Contractor Name(or well owner personally aban ping well onhis/her property) For multiple injection or non-water supply ivells ONLY with the same
�33 L construction/abandonmem,you can submit one form. /,
NC Well Contractor Certification Number t I ' ) 7b.Approximate volume of water remaining in well(s): `� (gal•)
q L V' ItL4 S VV`pi"� Do v�� FOR WATER SUPPLY WELLS ONLY:
Company Name
1 L' 7c.Type of disinfectant used:
2.Well Construction Permit#: ! 00 1 L4 0 23
List all applicable well permits(i.e.County,State,Variance,Injection,etc)iflazou» �(
7d.Amount of disinfectant used: � pt•fy(
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout C Iratzn a Chips or Pellets
❑Geothermal(Heating/Cooling Supply) t ential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery'
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation l 2 I/2y�
[]Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g)
O
4.Date well(s)abandoned: 7 2 /`'7 w `,.T
Sa.Well location: ,1 OCT J 2023
Facility/Owner Name Facility ID#(ifappli 8.Certifieatiol
fit` „� `�^'••o
�3.2 S ��� Gr�e�G Gk �-�iz,(V!`-IU`•en` ;�1::,..
Physic
at Ad sss,City,and Zip Signature of Certified\ C ctor or Well Owner Date
6t S, an Jr a y1 - By signing this form, I hereby certify that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constntetion Standards
and that a copy of this record has been provided to the ivell owner.
56.Latitude and longitude in de{,rt•eec/minntes/aecondF or•decimal degrcas:
(ifwell field,one lat(long is sufficient) 9.Site diagram or additional well details:
35. ���� N ^�� -7 y / You may use the back of this page to provide additional well site details or well
v W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL0 BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or noun-,rater supply
wells ONLY with the same constnuctiontabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well EN: abandonment to the following:
Division of Water Resources,Information Processing Uuit,
6b.Total well depth: —7 a (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
101b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: S (iu•) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: s (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): i(V (ft) 10c-For Water Supply&Iniection 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
6f.Inner casing/tubing length(if known): 9711CA_(ft) where abandoned.
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

WELL ABANDON1V1 N 1 r<r'CQRD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well ctor Info anon: WELL ABANDONMENT DETAILS
T� J7a.Number of wells being abandl red:
Welt Contractor Name(or well owner ona0y abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
n v
I^ constructiontabandonnreni,you can sub)I it one form.
NC 1WelllContractor Certification Number rr ^^ 7b.Approximate volume of water remaining in well(s): S (gal.)
Q FOR WATER SUPPLY WELLS ONLY:
Company Name
1 7c.Type of disinfectant used: �f/
2.Well Construction Permit#i:
List all applicable ivell permits(i.e.County,Slate,Variance,Injection,etc.)#known a
7d.Amount of disinfectant used:
3.Well use(checkwell use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) tial Water Supply(single) ❑ ement Grout ❑Dry Clay
❑IndustriaKommercial ❑Residential Water Supply(shared) oncrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date wells abandoned: .
5a.Well location:
V
1451 Y9%SO(- Z3
Facility/Owner Name J Facility ID#(if applicable) 8.Certification-
V T
Physical A dress,Ci`X
��c and Zip Signature of c ell Contractor or Well Owner V Date
.sZ��-�
I u� ��� By signing this form,I hereby certify that the well(s)was(here)abandoned in
County T— Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Jb.Latitude and longitude in degreec/minntee/cemndF or deeimnt dcgrccs: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
N -71 � Z You may use the back of this page to provide additional well site details or well
U W abandonment details. You may also attach additional pages if necessary_
CONSTRUCTION DETAILS OF WELDS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Altach well construction records)if available. For multiple it jection or nor-water supply
wells ONLY with the some con1st`rnctiordabandwmrenr,you can submit one jorm. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: A'/' abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft,) 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in,)
abandonment to the following:
6d.Water level below ground surface: (fL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):�Cira (fo 10c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
6f,Inner casing/tubing length(if known):
completion of well abandonment to the county health department of the county
_ _00 where abandoned.
6g.Screen length(if known): t 6� (ft)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013