Iredell_Well Abandonment_20231215 (2)

WELL ABANDONMENT RECORD
For Internal Use ONLY:
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I.Well Contractor Information: WELL ABANDONMENT DETAILS
Alfred Kiesling Jr
or Closed-L6o Geothermal ells having the same
Well Contractor Name(or well owner personally abandoning well on his/her well oor nstruction/dep hrobe/DPTmy 1 GW 30 ip needed. Indica
property) te 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 Chlorin e
7c.Type of disinfectant used:
Chlorine Well Construction Permit#:al*16L3 — (3 -14) 7 A
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:' �O ��C.-j
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that 1
❑Agricultural apply):
y)'
❑Municipal/Public &Meat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout
❑Irri anon 4,�,.4•� '° C1�Drill Cuttings
❑ Specialty Grout rr Y Grave Non-Water Supply Well: D�I+ -q.
❑Monitoring ❑Recovery ❑Bentonite Slutry`l (. 1 `� ��p Other'(explain under 7g)
Injection Well: lD'�rT tee; 6
7f.For each material sele`'teil ab4vp,Rrovide amougt o materials used:
❑Aquifer Recharge mate
Remediationv��Z�;1t_ y Il
❑Aquifer Storage and Recovery ` .oY I` L
❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g•Provide a brief description of the abandonment prgcedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) f
4.Date well(s)abandoned:
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5a.Well location:
r+- Z
Facility/ er me Facility 1D#(if applicable) 8.Certification:
a toPhysical Addre s,City,and ip 4Signatmerfttied 1 C tr c er
Yi�s 6/ Dat
County By signing this form, I hereby t�that the well(s) was(were)abandoned in
Parcel Identification No.(PIN) accordance with 15A VC
0 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.
(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 WELLS)BEING ABANDONED
Attach well construction record(s)ifavailable. Formultiple injection ornon-watersupply tive!!s SUBMITTAL INSTRUCTIONS
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit his 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: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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: 3z (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10t:.For Water SUDPIV&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): (ft.) abandoned.
6g.Screen length(if known):
ft.
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Form GW-30 North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016
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