Mecklenburg_Well Abandonment_20231122 (25)

WELL ABANDONMENT RECORD Far Internal Use ONLY: I f
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-42296 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 WELLS ONLY:
Company Name
2.Well Construction Permit#:
50000480 7c.Type of disinfectant used:
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.)fktoim
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic D 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)
RMonitoring ❑Recovery
Injection Well: 7r.For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑GroundwaterRemediation bentonite, 50 Ibs
❑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:
❑Geothetmal(Closed Loop) ❑Tracer grouted to surface using bentonite/grout.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
removed manhole cover and pad
4.Date well(s)abandoned: 11/20/2023
Sa.Well location: NOV 2 S Z0�3
Davey Tree 9705
Facility/Owner Name Facility lD#(if applicable) 8.Certification: :
� \�2'
11
6039 McDaniel Lane, Charlotte, NC 28213 1 -�.,� � /20/2023
Physical Address,City,and Zip Sign, of Certified W Contractor o 11 Owner Date
Mecklenburg 04902204 By signing this form, 1 hereby certify that the well(s)ivas(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:
(if well field,one lot/long is sufficient) 9.Site diagram or additional well details:
33.38876 N 80.689073 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 recont(s)ifavailable.Formu/tiple injection ornon-ivatersupplywelis
ONLY»-Ith the same construcuon/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the forth 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:
6d.Water level below ground surface: 26.45 (rt) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1
6e.Outer casing length(if known): 40 (ft.) 10c.For Water Suooly&lniection 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/tubing length(if known): Unk (ft.) abandoned.
6g.Screen length(if known): 15 (ft) r
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016