Mecklenburg_Well Abandonment_20240116 (2)

W#,LL ABANDONMENT RECORD For Internal Use ONLY- ?
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1.Well o/nttrra�cytor I o motion: WELL ABANDONMENT DETAILS
/ 7a.For Geoprobe/DPT or Closed-Loop,Geothermal Wells having the same
Well Contractor 1,iame(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is,needed. Indicate TOTAL NUMBER of
wells abandoned:
NC well Contractor CertihJ / Number 7b.Approximate volume of water remaining in well(s): (gal.)
41 FOR WATER SUPPLY WELLS ONLY:
Company Name Y p F 7c.Type of disinfectant used: "°t T"
2.Well Construction Permit#: r
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknoum i( IQ e
7d.Amount of disinfectant used: /
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): i
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout p4entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
PI-h`dustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation . ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation y o U
❑Aquifer Storage and Recovery ❑Salinity Barrier ' tC i
❑Aquifer Test ❑Stormwater Drainage ✓ 11 e i II
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the.abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
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4.Date well(s)abandoned: ` 01 - �' ,— � F � 4c `V-q¢"—
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5a.Well location- g' {��, /� JAN 16 2024
GL4' /J/, iY/01jeA, CO tfteJ'fir^ .^. l : ?•^a'. l Chi'
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
6y� � ��� n- 6� �•..•rpr
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Physical A dress,C'4 and Zip Signature of eriified Well Contractor or Well Owner Date
By signing this form, I hereby certify,that the well(s)was(were) bandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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 1i l one lat/long is sufficient) 9.Site diagram or additional well details:
�j G �l, 1 N �� �� 7 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
Attach well construction record(s)tfavailable. For multiple injection or non-water supply wells SUBMITTAL INSTRUCTIONS
ONLY with the same construction/abandonment,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: 1
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 00' 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:
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Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (fk) i
1636 Mail Service Center,Raleigh,NC 27699-1636
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fie.Outer casing length(if known): (ft.)
loc.For Water Supply&Infection 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
6f.Inner casing/tubing length(if known): ;� (ft.) abandoned.
6g.Screen length(if known): �1 (ft.) I j
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Jised 2-22-2016
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