Mecklenburg_Well Abandonment_20231024

WELL ABANDONMENT RECORD For Internal Use ONLY:
1..Well Contractor Information: WELL ABANDONMENT DETAILS
Mike Tynan 7a.For Geoprobe/DPT or ClosediLoop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2725-A wells abandoned: ' <1
i
NC Well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): (gal.)
I:
ET FOR WATER SUPPLY WELLS.ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit.#: WM0301320
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)iflmomv none
Meck SIP 70003164 7d.Amount of disinfectant used:,
3.Well use(check well use):
I
Water Supply Well: 7e.Sealing materials used(check'all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) sResidential Water Supply(single) Cl Sand Cement Grout ❑Dry Clay
❑Industrial/Comtnercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel .
Non-Water Supply Well: _ ❑Bentonite Slurry ❑Other(e�lain under 7g),
eMonitoring ORecovery -'
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation —350 lbs Hole Plug
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Removed 14 feet of 2"casing. Fllled well from bottom
I to the top with bentonite (Hole Plug).
a.Date well(s)abandoned: 10/13/2023 Resurfaced ground with soil cuttings.
5a.Well location: I,
Residential/Agri Property i �a •r= Fv"'_� J
Facility/Owner Name Facility IDff(ifapplicable) 8.Certification: OCT 2023
14720 Brown Mill Rd, Huntersville 28078 / _ 10/17/2023
Physical Address,City,and Zip Signature of Cert' d Well Contractor of Well Owner
Mecklenburg
By signing this form, I hereby cert fy that the ivell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has ben provided to the well owner.
(if well field,one lattlong is sufficient) 9.Site diagram or additional well details:
35 25 29.694 N -80 55 06.470 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 SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-watersupplvwells
ONLPwith the sane constntctionlabandonment,),oil can submit oneform.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TMW-1 abandonment to the following:
i
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 39 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addiition to sending the form to the address in 10a
8.5 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: 34.5 (ft.) Division of Water Resources, (Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 0 (ft.) 10c.For Water Sunaly&Iniecti on Wells: In addition to sending the form to the
address(es)above,also submit one bogy 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): 24 (ft-) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016