Mecklenburg_Well Abandonment_20231215

WELL ABANDONMENT RECORD For Internal Use ONLY: •
1.Well Contra r Information: WELL ABANDONMENT DETAILS '
,i1 h dry el As 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
C, C/c) wells abandoned:
i
NC Well Contractor C 'fication Number 7b.Approximate volume of water j remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
Compaq Name •
/10
,r� 7c.Type of disinfectant used: ?/ G/
2.Well Construction Permit#: v(��Or3'List all applicable well construction pe (i.e.UI ounty,State,Variance,etc.)if known
7d.Amount of disinfectant used: O 1
3.Well use(check well use)::
Water Supply Well: 7e.Sealing materials used(check all that apply):
•
❑Agricultural ❑Munic'pal/Public 0 Neat Cement Grout - I., .i •;I.—,D Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) 0 Sand Cement Grout r� I�"''$,.r'C1,,, 12v,
m❑Industrial/Comercial ❑Residential Water Supply(shared) on Ccrete Grout UC CI 1 .. ❑Diiirdutiings
❑Irrigation • 0 Specialty Grout layer, 1 -� Z6tGlavel
c.,
Non-Water Supply Well: r'infer,.,,
0 Bentonite Slurry .':^:., to Other(explain under 7g)
❑Monitoring DRecovery �'1•7'yyh:•,:, (..t
Fei,
- .Injection Well:- . - - - - - - - - 7£For each material selected above,provide amount of materials used:
❑Aquifer Recharge . ❑Groundwater Remediation //
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control •
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop). ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: /C7 /I 412I
' .5a.Well location: !
(\e'14) r5 ", C4p^r-- , .-.
Facility/Ownerame Facili ID#(if applicable) 8.Certifcation: •
Physical Address,City,and Zip Signature of Ce ' ed Well/31
Well Owner Date
47—
l 42 tA By signing this form, I hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NC/IC 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 latllong is sufficient) 9.Site diagram or additional well details:
N 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 records)Oravailable.For multiple injection or non-water supply wells _
ONLY with the same construction/abandonment,you can submit one form.
�a 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: l/ abandonment to the following:
• Division of Water Resources,Information Processing Unit,
6b.Total well depth: A/4 (ft) 1617 Mail Service Center,Raleigh,NC 27699:1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: Z (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: Ai/i (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service'Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): d (ft) 10c.For Water Supply&Injection 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 bounty health department of the county where
6E Inner casing/tubing length(if known):A(i.t
a��. (ft.)
abandoned.
6g.Screen length(if known): (ft)
•
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
.

•
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contra In rr don: WELL ABANDONMENT DETAILS
• /` G .J r t`' �> 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
'0 (// wells abandoned:
NC Well Contractor firation Number 7b.Approximate volume of water remaining in well(s): /(//7` (gal.)
/ f FOR WATER SUPPLY WELLS ONLY: > J
Company Name / f 7c.Type of disinfectant used: i 7-"7` 7/T
2.Well Construction Permit#: ®©/ q02 C)o: t
1
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)/fknown Ver.,
7d.Amount of disinfectant used) 7
3.Well use(check well use):: i
Water Supply Well: 7e.Sealing materials used(check all that apply):
•
0 Agricultural ' tpal/Public 0 Neat Cement Gr`t7 -,-. .,, I 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) 0 S ement Grout• o�,, -,'• i,ifyG-.DrvClay
❑Industrial/Commercial OResidential Water Supply(shared) Concrete Grout k,g,prtl Cuttings
❑Irrigation • 0 Specialty Grout DEC . 20^ ❑Gravel
Non-Water Supply Well: 0 Bentonite S ltzyri;yyri., � ^` `�❑ Other(explain under 7g)
❑Monitoring ❑Recovery -�y4.a I :'",'�'"'c:a..�1 t
-Injection-Well: - - 7f.For each material seTee'�Eatalb7g;prdvril ii'mount of materials used: -
❑Aquifer Recharge ❑Groundwater Remediation ‘ _ I6,G�9 s
❑Aquifer Storage and Recovery 0 Salinity Barrier /L�
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 0 Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop), OTracer /
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) , -1' 4/f!� , ('on C/sA.
4.Date well(s)abandoned: /b /�(�d'�
I
5a.Well location: 4
` Ce7/ G9 `i/� i
Facility/Over Name Facili ID#(if applicable) 8.Certification:
4. . -'-'—‘ Z__IZZ42,2_3
Physical Address,City,and Zip Signature of Certified Well Contractor,or Well Owner Date
c/ By signing this form, I hereby dertify 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: `(if well field,one 1st/long is sufficient) 9.Site diagram or additional well details:
N 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 constructionrecord(s)tfavailable.For multiple injection or non-water supply wells -
ONLY with the same construction/nment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a Well ID#: abandonment to the following:
�r Division of Water Resources,Information Processing Unit,
,6b.Total well depth: (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
410b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: (hi) 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: ! (/.d (h) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): rf— (ft) 10c.For Water Supply&Injection 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): .;.9. (ft.) abandoned.
6g.Screen length(if known): A/4 (ft)
•
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
1

WELL ABANPONMEN'1' RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
A[cll.Gee-i Ey-cwt.C.t 5 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 GV�-30 is needed. Indicate TOTAL NUMBER of
ZE 7 3 11 wells abandoned: '
NC Well Contractor Certification Number 7b.Approximate volume of wat it remaining in well(s): I ° (gal.)
Ftrt-V.ci S Gl.)e.LI Pi—PG/ in? ) • FOR WATER SUPPLY WELLS ONLY: '
Company Name /I 44 Ct
Ir
7c.Type of disinfectant used: )4 T
2.Well Construction Permit#: I CO 11 ZZ 1
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known f _C
7d.Amount of disinfectant used: C) r
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials u hi!(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout .i....i,� ', •, i[ eaitonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 1i esidential Water Supply(single) 0 Sand Cement Grout 0 - ❑7Dri y
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout Cuttings
❑Irrigation 0 Specialty Grout l it�C,^ Liz i3;o,,M C❑JGravel
Non-Water Supply Well: 0 Bentonite Slurry Ctw'' :(?ti `%L-J Qtl}e�r(explain under 7g)
.__�-_DMonitoring___ ____ _ _. . ❑Recovery -- - _ _ - -
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation /00 ) 17 50Aquifer Storage and Recovery ❑Salinity Barrier /
❑Aquifer Test ❑Stormwater Drainage .
❑Experimental Technology 0 Subsidence Control
7g:Provide a brief description of the ab donment procedure:
❑Geothermal.(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 5`o w I M )j L4 ).Q bt'
4.Date well(s)abandoned: 1. i 2-cl 3 . .
5a.Well location:
tt� 1 ,/� I
{{�hiGer� 1,L�eL 1/a.i.)2 •
Facility/Owner Nadfe Facility ID#(if applicable) 8.Certifi
cation:
600 f©ock-/4 e-AfLn.. Letr'ioieIAC(2ni(, /i/ AA" i (-2A--2-3
Physical Address,City,and Zip Signature of Certified Well Contractor,or Well Owner Date
filA c,k s 6 Q h'anv U(sq 039--I !a 1!0 C J By signing this form,I hereby cert5 that the well(s)was(were) abandoned in
County J Parcel Identification No.(PIN) accordance with 1 SA NCAC 020.0100 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 lat/long is sufficient) 9.Site diagram or additional well details:
N 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 record(s)if available.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
A I A 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID/I: / abandonment to the following: i
666 Division of Water Reslources,Information Processing Unit,
6b.Total well depth: SO (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
i
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: , (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: 1
6d.Water level below ground surface: (ft.) Division of Water,Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): - M('4 (ft.) l0c.For Water Supplv&Injection 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
Nr/ ft.
abandoned.
6E Inner casing/tubing length(if known):
6g.Screen length(if known): Al ( )
/1+ (ft.)
1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016