Mecklenburg_Well Abandonment_20231122 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
i
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 Ci-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 WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: 50000480
List all applicable well construction permits(i.e-UIC,Calmly,State,Variance,etc.)if Imo wn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7c.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a 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)
eMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation bentonite, 50 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage grout, approx 94 Ibs'
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer grouted to surface using benton ite/g rout.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
removed manhole cover and pad
4.Date well(s)abandoned: 11/20/2023
5a.Well location:
Davey Tree 9705
Facility/Owner Name Facility IDk(if applicable) 8.Certification:
6039 McDaniel Lane, Charlotte, NC 28213 .azl 1`1120%202
Physical Address,City,and Zip Si lure of Certified Well cotract6r or well owner Date
Mecklenburg 04902204
By signing this form, 1 hereby certify that the tive11(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:
35.266322 N 80.762863 You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Aitacbwellconviructionrecord(s)ifavailable.Formultiple injection ornon-watersupplywells
ONLYadth the sane 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-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 45 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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:
29.57 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (it) 1636 Mail Service Center,Raleigh,NC 276994636
6e Outer casing length(if known): 45 (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 where
6E Inner casing/tubing length(if known): Un (ft) abandoned.
6g.Screen length(if known): 15 at)
Fran GW-30 North Carolina Department of Environmental Quality-Division of Water Reso•'urces Revised 2-22-2016