Mecklenburg_Well Abandonment_20231204 (2)

WELL ABANDONMENT.RECORD. _ For Internal Use ONLY: =
This'form_can be used for single or multiple wells
1.Well Contractor Information:. WELL ABANDONMENT DETAILS
KENNY SARGENT
7a.Number of wells being abandol ed: ' 1
Well Contractor Name(or well owner personally abandoning well on his/her propeity) For .multiple - h jection" or non-water supply .wells .ONLY. with' .the same
constntctionlabandonmem�you cal!submit bneform.
A-:4226 i
67..5
NC Well Contractor Certification Number
- 7b.Approximate volume of water;remaining in well(s):, (gal.)
GEOLOGIC-EXP LO RATION FOR.WATER;SUPPLY WELLS'ONLY:. '
Compauy,Namc 7c:Type of disinfectant used: .
z:Well Construction Permitm. - 70001364/WM03013-18
List dll applicable well'construction permits'(r:e.County,State,Variance,.etc.)ijknown 7d.Amount of disinfectant used:
3:Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check,all thatapply) . "
❑Agricultural ❑MunioipaLTublic. ❑Neat Cement Grout " ❑Bentonite Chips or Pellets
❑Geothermal(Heating/CoolingSupply): ❑Residential Water Supply "D Sand Cement,Grout: ❑Dry Clay,,.
PPY): PPY . " . -
❑Industrial/Commercial 'DResidential Water Supply(shared)" ❑Concrete Grout ❑Drill Cuttings
❑Irri ation : ❑ Specialty Grou
t ❑Gravel
Non-Water Supply Well: 9 Bentonite Slurry 0 Other(explain under 7g), .
[Emonito4g ', ❑Recovery.
Injection Well: 7E For each material selected above,provide amount of materials used: .
❑Aquifer Recharge ❑GroundwaterRemediation K0 GALLONS.
❑Aquifer Storage and Recovery ❑Salinity'Barrier..
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology. :.. . ❑Subsidence Control 7g..Provtde a brief.descripHon of the abandonment procedure:
l[]Geothermal(Closed Loop) ❑Tracer - ABANDONED VIATREMIEPIPE WITH BENTONITE SLURRY'
'Odeotliermal,(Heatinp)Cooliiig'Rett6) DOther(explain under 7g)
10/1.6/23 r; .
4.Date well(s)abandoned: fit
So.Well location:
202.3
UNIVAR In
8.Certification::
Faeility/Owner Name Facility ID#(if applicable)
5010 HOVIS ROAD CHARLOTTE 282.08 . '^ : 1.0/20/23
Physical Address,.City,and Zip Signature of Certified Well Contractor or Well Owner' Date
MECKLENBU.RG By signing this form;"I hereby'certify 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 fieldo one lat/long is sufficient) 9.Site diagram or additional well details: .
350.16' 07.67" 80e 53' 53.27" . You may use the back of this page to provide;additional well site details or well
1V W : abandonment details. You-may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction reeord(s)if available. For multiple injection or.non4ater supply
wells ONLY withthe.sameconstructidnlabandonment,you can submitonefonn. IOa. For All Wells: Submit this form within 30'days of completion of well
6a.Well la# " VAP-1. abandonment to the following:
Division.of Water Quality,Information.Processing Unit, .
6ti.Total well depth:. 60•0 (ft,) 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Iniection"Wells: In addition to sending the form to the address in 10a
C 0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
15.0 Division of Water Quality,Underground Injection Control Program,
6d,Water level below ground surface: 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Inlection Wells: In addition to sending'the form to
6e.Outer casing length(if known): (fL) 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 abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Fonn GW-30 North Carolina Department ofEnvuonment and Natural Resources-Division of Water Quality Revised March 2013