Mecklenburg_Well Abandonment_20231122 (24)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed'Loop 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
N C-4229 B wells abandoned: I ;
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <3 (gal.)
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
50000480 7c.Type of disinfectant used:
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.)ifknowrt
7d.Amount of disinfectant used:;
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check'all that apply):
❑Agricultural ❑Municipal/Public R Neat Cement Grout 11 Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑lni ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation bentonite, 50 lbS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage grout, approx 200 Ibs
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure,
❑Geothermal(Closed Loop) ❑Tracer grouted to surface using bentonite/grout.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
removed manhole cover and pad
11/20/2023 e_
4.Datewell(s)abandoned: > 9 !
5a.Well location: N n V 9 2 n 2-
Davey Tree 9705 L'
Facility/Owner Name Facility ID#(ifapplirable) 8.Certification: �•-^ ? i�;;;z
6039 McDaniel Lane, Charlotte, NC 28213 •., �'
"'C�1%2�0/2023
Physical Address,City,and Zip SiVe ofCertified Well Can for or Well Owner Date
Mecklenburg 04902204 By signing this form, I hereby certify that the,vell(s)was(were)abandoned in .
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the tvell inviter.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional welt details:
33.390111 N 80.66711 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(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a Well ID# MW-7A abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth: 40 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
tic.Borehole diameter. 8 (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 surface: 29.55 (ft.) Division of Water Resources,!Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
40 10c.For Water Suaaiv&Iniection,Wells: In addition to sending the form to the
6e.Outer casing length(if known): (fk) 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/tubing length(if known): Unk (fL) abandoned.
6g.Screen length(if known): 15 (ft.)
Forst GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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WELL ABANDONMENT RECORD For Internal Use ONLY:
� I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-L lop 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
N C-4229B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water°remaining in well(s): <3 (gal.)
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLSIONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
50000480
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:l
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public I,Neat Cement Grout S Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation bentonite, 50 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StonnwaterDrainage grout, approx 200 Ibs
❑Experimental Technology []Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer grouted to surface using bentonite/grout.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
removed manhole cover and pad '
4.Datewell(s)abandoned: 11/20/2023
Sa.Well location: u z
Davey Tree
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
6039 McDaniel Lane, Charlotte, NC 282132 iy -1
�'1'1°/2012023
Physical Address,City,and Zip Si ture of Certified Wellfeimmactor or Well Owner Date
Mecklenburg 04902204
By signing this form, I hereby certo 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'
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:
(ifwell field,one lat(long is sufficient) 9.Site diagram or additional well details:
33.36745 N 80.65612 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(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable.For multiple injection ornon-watersupply wells
ONLY with the same consrruction/abandonment,you can submit onefornt. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35 (ft) 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: 4 '
6d.Water level below ground surface: 29.55 (fL) Division of Water Resources,Uerground Injection Control Program,
1636 Mail Service Cen tidter,Raleigh,NC 276994636
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6e.Outer casing length(if known): 35 (ft) 10c.For Water Sunmly&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 cotinty health department of the county where
6E Inner casing/tubing length(if known): unk Aft) abandoned.
s
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6g.Screen length(if known): 15 (ft) j
Revised 2-22-2016
Form GW-30 North Carolina Department of Enviromnental Quality-Division of Water Resources