Iredell_Well Abandonment_20231215

WELL ABANDONMENT RECORD For Internal Use ONLY:
I.Well Contractor Information: WELL ABANDONMENT DETAILS
Alfred Kiesling Jr
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
3266—A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal,)
B & K Well Drilling Inc FOR WATER SUPPLY WELLS ONLY:
Company Name 0,3 Chlorine
'7 7a Type of disinfectant used:
-Chlorine
Well Construction Permit#:46
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.)iflanown /
3.Well use(check well use): 7d.Amount of disinfectant used: + 0(J�t CAP S
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑A cultural PP y)'
❑MmmicipaUPublic ❑Neat Cement Grou �ntonite Chips or Pellets
❑Geothermal g/ g Supply) g ) '
(Heating/Cooling Coolie Su 1 eResidential Water Supply(single) ❑ Sand Cement Grout �-�,�' ,�k_-� -2 ,p,]Z Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 5Toncrete Grout DF " r` tl/r `
`r Gln'II uttings
❑Ini ation 1.
❑ Specialty Grout 1,5 Gravel
Non-Water Supply Well:
❑Bentonite Slurfj%CF,`„ ;iC Other(explain under 7g)
❑Monitoring ❑Recovery Jl?r;,��
Injection Well: . r
7f.For each material select eiitatibr(e,�rovi7d�a'biount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier MA
��
❑Aquifer Test ❑StormwaterDrainage � (,1/t.C. ,
❑Experimental Technology ❑Subsidence Control
[]Geothermal(Closed Loop) ❑Tracer 7g•Provide a brief description of the aba donment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) L(❑f 7�. J .
4.Date wells)abandoned: 02' D..
5a.Well location: �n
iJ'Gy+r N �a V L s��1/ •
Facility/Ovfner Name Facility 1D#(if applicable) 8.Certification:
Physical Address,City,Ad Zip Signat*fetied-l"ont=ractor
Date
-173
Count T G�� p By signing this form, I hereby certify well(s) was(were)abandoned in
y Parcel Identification No.(PIN) accordance with 15.4 NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
N Kr 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)ifavailable. For multiple injection or non-watersupply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
62.Well ID#: abandonment to the following:
?� Division of Water Resources,Information Processing Unit,
6b.Total well depth: ✓ (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Iniection 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:
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): ! (g,) 106.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): (g,) abandoned.
6g.Screen length(if known): (g,)
Form GW-30
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016