Mecklenburg_Well Abandonment_20231122 (17)

EIN U M()" For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDON5ENT DETAIL 9
9a.For GcoprobeA)PT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(orwell owner personally abandoning well on his/her property) well construction/depth,only 1 OWL30 is needed. Indicate TOTAL NUMBER of
wells abandoned: I
NC Well Contractor Certification Number 7b,Approximate volume of wa her,remaining in wen(s): l o (gal,)
C1 �'�G� d y`oy L.J FOR WATEItSUPPLY WELLS'ONLY:
Company Name L f
/ '�� 7c.Type of disinfectant used: 1 1
2."Well Construction Permit#:_ _ � G® �'i�-1
List all applicable well rnnstnrct7o»permits(I.e.UIC County,State.Variance,etc.)ifknown _ L
7d.Amount of disinfectant used:
3.Well use(check}yelt case):
WaterSupply Well: 7e.Sealing.materials used(check all that appllyy
❑Agricultural QMunicipal)Public ❑Neat CemeritGrout apply
Chips or Pellets
❑Geothermal(fIeatinglCooling Supply) twiftesidential Water Supply(single) ❑Sand Cement Grout 17 Dry Clay
❑IndustriallCommercial oResidential Water Supply(shared) Q Concrete.Grattt O Drift Cuttings
-111mg8tion ❑Specialty Grout ❑Gravel ..
Non-Water Supply Well, p BentoniteSi
_l�lotutodn �_ _ _ _ _ ___ °m' _ l CJ Other(explain under 7g)
g - -=C1Recovery — +— - un — -
Injection Well: X For each material selected above,provide amount of materials used:
OAquifer Recharge ClGroundwater Remediation
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology- DSubsidence Control
❑Geothermal((Closed loop) QTracer 7g.Provide a brief description of the baridoament procedure:_
17Geathetmal(11cating(Coolin Return) ClOther.(ex fain under
7g)
f
4.Date well(s)abandoned:
511.Wen location: «0 V 2 ? 2023
racir /6%v=N
ty erne FahiilitylDii.vappucable) 8.CertiIIeation: 'h
2-3
Physical Address.City,and Zip .
Signature of Certified Well Contractor arWell Owner Date
County -"" tifi By signing this form,I hereby cen6 that the wells)was{were)abandoned in
Parcel Idencation No.(PIN)' accordance with 15A NCAC 02C;0160-or 2C.0200.Well Construction Standards
5b.Latitude and longitude in degrees/minutes/secofids or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lattlong is sufficient) 9.Site diagram or additional well details;
N W .You may use Uie back of this page to provide additional well site details or weU
- - -- - abandonment details. You may also attach additional pages if necessary:
CONSTRUCTION DE'I'�,M OF WELL(SBj M ABi1L111DONED SUBM111 tTAT.IN�fRifCTIO1V5'
AttachweilconsiructionrecorWs)f/'awilable.Forinuliipleh9ectt000rnon.watersupplywe&
ONLYwith ihesome construction/abandonnrent,you can submit one form.
t too.For-Aft Wells: Submit this form within 30 days-of completion of well
6a.Well ID#: abandonment to the following:
/ Division of Water Resources,Information Processing Unit,
6b.Total well depth: 7a (a) 1617 Mali Service Center,Raleigh,NC 27699 4617•
lob j�or Infection Wells: In additio6 to sending the form to the address in 10a
6e.Borehole diameter: (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: 0 (ff) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,*Raleigh,NC 17699 4636
6e.Outer casing length(if known): A (R,) toe..For Water Sunnlv.&blection Wells; In addition to sending the form to the`
address(es)above,also submit one copy of this forth within 30 days of completion
Gi:Inner casing/tubing Length(if!mown), (tlf.) of well abandonment to the county health department of the county where
abandoned.
6g.Screen length(if known): (B,) '
corm GW-30 North Carolina Denartment of ry virnn..v t. i ram.uti-roc..,.,.,...,.cnr_.r n� r�l