Mecklenburg_Well Abandonment_20231204

WELL.ABANDONMENT RECORD. Fot•lntcroal'UseO-NLY:
This form,can bepsed for single or multiple wells.
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1.,Well Contractor Information:. WELL ABANDONMENT DETAILS ,
KENNY SARGENT 7a.N
• . .. . • umber of wells.being abandoned:
Well Conliactor Name(or well owner personally abandoning well on his/her propeAy) For` .multiple injection or non'water supply ,wells_ .ONLY. with the same
cohstruction/abiindonment,you can submit one form.
A-:4226 . .'
NC Well Contractor Cer"cationNumber
7b.Approximate volume of wat er remaining in well(s):,' 60.0•
GEOLOGIC EXPLORATION . . FOR•WATER'SUPPLYWELLSONLY:
Company,Namc
7c.Type,of disififectant used: .
z.Well Consttvction.Permit.#: . 70001'364/WM 03013.18
List all applicable well construction permits Ci;e.'County,State,Variance,.etc.)if known 7d.Amountof disinfectanbused:
3:Will use.(check well use):
Water Supply Well: 7e.Sealing materials used(check all thatapply):.
❑Agricultural ❑lvlunioipa]/1'ublio ElNeat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(HeatinW.Cooling Supply): ❑Residential Water Supply(single) ❑Sand Cement Grout - ❑ Dry Clay
Olndustrial/Commercial- l7Residential Water Supply(shared) ❑Concrete Group ` a o �,, 3=6rill Cuttings
l7Irri anon - ❑ Specialty Grout ❑Gravel
f1
Non-Water.Supply Well: Z Bentonit6 Slurry n r r t�..: Z`/ Other(explain under 7g)
Elmonitoring ❑Recovery. -
Injection Well: 7L For each material-selected 3b6W;pr 6vidc amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 97:5 GALLONS
❑Aquifer:Storage and Recovery. .. 11SalinitVB"arrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology: .. ." Subsidence Control 7g,provide a brief.description of the abandonment procedure:
❑Geothermal(Closed Loop)• ❑Tracer
�ABANDONED.-VIA TREMIE PIPE WITH BENTONITE SLURRY . .
❑Geothermal(Heating/Cooling Return) OOther(explain under 7g).
4.Date well(s)abandoned:
10/18/23
5a..Weil location:
UNNAR
Facility/Owner Name Facility1D#(ifapplicable) S.Certifieation:, '.
5.010 HOVIS ROAD'-'CHARLOTTE '28208ul ". . : '1.0/20/23
Physical Address,:City,and Zip Signature of Certified Well Contractor or Well Owner', .. Date .
MECKLENBURG By signing this form;I hereby certi�y that the well(s)'was_(were):abandoned in
County :. Parccl.IdentificationNo,(P". accorda»ce with 15A NCAC 02C 1010.0 or 2C.0200.Well Constructioi Standards
and that a copy of this record has been provided to the well owner.
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:.
Qfwell field,one lat/long is sufficient) 9.Site diagram or additional well details: .
357 16' 07.67° 80o 53' S3.27" You may use.the back of this page to provide additional Well-site.d'eiails or well"
N. W' abandonment details. You may also attack additional pages if necessary.
CONSTRUCTION DETAILS OF WELLISI BEING ABANDONED SUBMITTAL INSTRUCTIONS,.
Attach well construction record(s)if available. For multiple injection or:mm-water supply
wells.ONLYwith thasame construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30•days of completion of well
6a..Well ID#.
�/AP-2. . abandonment to the following:
lity,Information Processing Unit;Division.of Water Qua ,
65.0 1617 Mail Service Center,Raleigh;-NC 276994617
6b.Total well depth': . (ff.)
10b.For Inlectlon Wells: In addition to sending the form to the address.in 10a
-6.0. above,also'submit one copy of this fonn'within 30 days of completion of well
6c.Borehole diameter: (in.)
.abandonment to thefollowing:
25.0 _ Division of Watef Quality,Underground Injection Control Program;
6d.Water level below ground'surface: (ft) 1636 Mail Service Center,Raleigh,NC 276994636
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10c.For Water Simi fly&Iuiection'Wells: hi addition to sending.the forth to-
6e.Outer casing length(if known): 00 the address(es) above, also subniit i one copy of this form within 30.days of
completion of well abandonment'ito:the county health department of the county
6f.Inner casing/tubing,length(if known): (ft.)• where abandoned. I•
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March.1013