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Home My WebLink AboutMecklenburg_Well Abandonment_20240301 it i WELL ABANDONMENT RECORD ` ii e North Carolina Department of Environment and Natural Resources-Division of Water Quality c4,� ® WELL CONTRACTOR CERTIFICATION# Li I 6 W 6 I 1 1.WELL CONTRACTOR: 5. WELL DETAILS: Roy Charles Killian,Jr a.Total Depth 16 rft. Diameter:20 in. Well Contractor(Individual)Name b.Water Level(Below Measuring Point): DRY ft. Summit Measuring point is 0 . ft.above land surface. Well Contractor Company Name 10121 Pineville Distribution St 6. CASING: Length Diameter Street Address ' Pineville NC 28134 a.Casing Depth(if known): , ft. in. City or Town State Zip Code b.Casing Removed: ft. in. (980 ) 581-7105 , Area code Phone number 7. DISINFECTION: (Amount of 65%75%calcium hypochlorite used) 2.WELL INFORMATION: 8. SEALING MATERIAL: SITE WELL ID# (if applicable) Neat Cement Sand Cement STATE WELL PERMIT# (if applicable) Cement lb. Cement lb. COUNTY WELL PERMIT #(if applicable) Water gal. Water gal. Bentonite DWQ or OTHER PERMIT #(if applicable) F. ,.., Bentonite lb: e f,; 1 tr."':-. WELL USE (Check applicable use):_ Monitoring 1 Residential iii t Type:D Slurry _I Pellets M unicipallPublic -1 Industrial/Commercial 1 Agricultural Water gal. MAR0 1 2024 _ Recovery __ Injection - Irrigation Other mfjr�+" i:,D ?r�. I Other(list use) Type material Concrete Grout Amount 1.5 CU/YD 3.WELL LOCATION: COUNTY Mecklenburg QUADRANGLE NAME NEAREST TOWN: Matthews 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL: PIN 19331108 Concrctc grout was'placed into thc well from thc (Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) surface. The well Was completely filled with TOPOGRAPHC/LAND SETTING: approximately 1.51Cubic Yams. J Slope _I Valley _ Flat ✓_ Ridge._I Other (Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of tlwell on the back of this form showing total depth,depth and diameter of screens(if any)remaining LATITUDE 35 °7 ' 26.1900 "DMS OR 3X.XXXXXXXx OD in the well,gravel interval,intervals of casing perforations,and depths and LONGITUDE 80 a 41 . 57.2900 "DMS OR 7x.xxXXXXXXX/D types of fill materials,sed Latitude/longitude source: V3PS propographic map 11/10/23 (location of well must be shown on a USGS topo map andattached to 11. DATE WELL ABANDONED this form if not using GPS) I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF 4a.FACILITY-The name of the business where the well is located.Complete 4a; THIS CORD HAS BEEN PRVIDED TO THE WELL OWNER. (If a residential well,skip 4a;complete 4b,well owner information only.) 7117j4: 5-7(k-L...----- FACILITY ID# (if applicable) 11/10/23 I NAME OF FACILITY SIGNATU E OF C WELL CONTRACTOR DATE I STREET ADDRESS SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE _ City or Town State Zip Code (The private well owner must be an indiLidual wpersonallyebandons his/her residential well in accordance with 15A NCAC 2C.0,113.) 4b.CONTACT PERSON/WELL OWNER: Roy C.Killian Jr. , NAME Zack Waddell PRINTED NAME OF PERSON ABANDONING THE WE LL STREET ADDRESS 3060 Peachtree Road NW Suite 560 GA 30305 Submit a copy to the owner and the original toiti ,is on;�,of Water Qua ty,- Information,Processing,-1 Form GW-30 • 662 aij 5e tyi enter,,Ra h NC1i617Ar;Phone:(919)807-6300 {� Rev.5/10 • , . . VVE-1,41i AtiANIIONMENT:RAC()1(0. Per IntemalIfse ONLY: ' 3 .• • . • . • .• - - I . . . I.Welt Contractor Information: IPELLAIWIDONMENTIDETAILS , • . , 4,1,,....Q....1, 1-5.,-,nc..., s 1 1- • . In For Geoprobe/DPI•or ClOsed-toopGeotheritud Wells having the same: - - Well eootteetet yank,(of;ell ovint*Ootai)nally abandeniog welj oe hisilterieviletth .well eenslniqtion/defik only 1 OW-3o is needed.2_qIndia,TOTAL NUNIBPR„ol 71 --/I- •-: wells abandoned; 'I! N ; , 1 . , . . . . .- . . . -NC Welt Centnieter Certification Number: 7b.Approithitte volume of water retaining in well(s):. 2-10 (gel, . . • ..- F;Ce-r•CIS flifer•li il.--04. 3°U PA' A 6 I FOR WATER SUPPLY NI/ELLS ONLY: , . . 6)-FiPanY Nome - si ' r .7e.Type of&infected used: . ("4.-T • .. .12,..wen•cvn.ktru'eliooern*ifi: ,.)00 .2-1.391, ) - •...• :Listamopplioaftwooiondniaio-fiomioAc Vic;Ceent)).Stole;Variance etc). Volown t 4._a." 7d.Anmunt of tlistreetnnt.risedr __,,,,.... ...... ____—...—...— • - . - 3.Well use(checitWellitse):"--;- . . . , .,• .W. _ , , . , ater Supply Went ''-,-- 7e.Sealing ninterials used(check all that appky): . . CrAgtimdttual•.2- . ::- 0MtmleilitilAt blic 13 Neat Cement Grout • : Otetitonite Chips or Pellets 0Geothetandi(Heatittg/CoOling-SOpply) iilifett identini Water Supply(single) •-:. OStuidCctent Grout • - • 0 Dry Clay• ' ..- OiodaStrialiettnielerciat ..; '0Residentjal Water Supply(Shared) 0 Concrete Grout - :' Cl Drill Cuttings. .•- - Clirrigritioa • ,. . -.',..--• . . . '. ,,., . • ,-.:70 Specialty Grout i -0*Gavel- ---=------------- • 'Non-Water SlipOriVeui -:..::--- -- ' - - • 15 BentOnite Shiny 0 Other(explain under 7g) ,. '.- . Oiniaitwing - -• , • ,''..: . ORecotrety- - • Injection Wq:- • • `2:::. . - - - ' - If Fur each material selected above,provide amount of materials used: PAtitiirer.1teehttri - 'f-;-,-.- 0Groundwater-llemediation- -) 56 I.b.S• :,• . 04quifer Storage and Recovery--' CISalittity Barrier ... " .. 0Armifer Test -•., ,"•:':-:- 0Stormwater Drainage . .. . . . . 0Experiineinallicliniilogy ;;;: .. 0SubsidenceContiot . 7g-PrOitle 0'brief deserlptinn elite alma onmentproctOrm :nemOthimml.(cioed I.bop)- ---- „ . .Effacer • -- L i •L • • C30 cot h er nial OfiatineCoolitil Return) ..00ther(explain Under-7g) ]c'‘-`4 J -c-1 i "°\-1/X- . • . . , . • - . ., . - r.".•:. 7-- . • c &Date well(s)rahandiMedt.....,.„ Z•7 77772;4 kAL-CtLi V L Li , .,.. _ . ... Si.WelliOcatieur -...;-: . ' .:. . ' - ' - MAN. 0 1 10Z( -Ff 1 0 e rYi•: E o - . , . ... , , • • lotorrria'iter:Prr.-4604:4:9 Ustll ieeit.00,OterOamo? ' 1'1.. . . FacilityliM(irapplimble) - 8.Certhicationk : 151-0 1 Ra.ns.0 ii.i,Rd., gueci-e.,,e 'vt)te:A/1;C, 4 .127i? :- ',.1 ',: . .2-7-2-e-1 PhSraletitMdr!s,-City.and Zip :- Sistiatu*Of Cfied Wei Coetteetcifot Weg Owner Date . ' Ak/en,btlij _ . Crag-0 Ft-t.6: • ..„, . , . , , - 13y-01gnitig thi.0 form,f hereby 90:14:that the well(s)was(ire:9)abieulonetil in coutty, ' i,... . • Parcel IdeiilifidniOn NA(PM) aecOdanedIvilk 15-4i1C/IC:.02C.:61.00 9t2C',1)200•Well Canso:teflon Siandqn A awl:hat:2 coisy i-degrecs/rainutesi of1140 re200,40 4001;:provie,e01!o :51;-tallyg.fle R-04 lOnellt4ilsr.conds or dectrual degrees: .. 0-fWot.6thi„rite latlienaiS seffgetem) " • . . . ' 9.:Sitediallran34?Failditlotial-Well details; - - - . • - .. • -• - •. ..-•:•: .;"'. . :- -J-i4- . -N ••- . - - vp .1Yibtilt!ciii2:Lu!!.t.ela.cl(yOofnlliilltille'.t provide 04400 well site details or well may,also,altaph additiMull pages if necesstuy. " ""'' "5 . . — .CONSTAIICITONlIkifitiA OP*ELIStREINOA11.4.14130NED- • _ sunatrel. arjk 41.1kici" . ..r...,•• . Affeel:WIlciewrecIiir,:ret99110)Vavailebie:Pitntii141010lactlehoriver-u*terilipplywag . •-•`•1•"..-:' ,.---•••', ,. .. 01V4Tivii1110000:iiwuriitcil,Wiabrovlowtelityve eters:thing a:0Am „ .. - I: . . 10a. or AI Wells: Submit this form within 30 days of completion of well 60.Weil Mt - - -.Pi Liek -. . abandonment tO the folloWing. . . .. ' .. Divisionof Water,Bcsourees;InforouttiOn Processing Unit, fib Total Well depth '-'- -'S 0 . (IV 1617 Mail Servi&Center,Itatelgit,NC/769944.17,.., - I ....„-- -.• ' • . -"10k. ?or injection Wells: In addition to sending dm'fort to the address in.10a, .: fie.Borehole diamete, r: •::',-. _ 2- ..:, (In) ' above,also subMit.one copy of this fort within 30 days of completion of well abandonment to the following ' .- .• . - 6d..Water leVel,below ground sin-lime: ,, 40 - • .(ft.) -Division of Water ResOurees Undergroundlnieetion Control Program, 163611101 Scilvice-C.enterf Daleigh;NC2769946;16 •, • 1 ' , 10c.For Water.Surioly 8f Inicetlop-Wells:in additien to sending**form to the 60.,'Outer crisinglength(ithnown): AI 7(it)- • address(es)above,alio-submit-One edgy of this form within 30days of completion . • . of well abandonment to the County health department of the county *here Ing/I 'abandoned. • ' a Ander esstthing!Crag*(If known): • • (IL) ' :ALIA . ... • -.:..'•.- _ . ,T. 6g.Serceileigth(If known): 41/./1 (ft.)(ft.) • 1 . - ••:,--L • ,-,- - • . . . .. . . • • . . • WELL AttANDONIVIENfitECOICO For Internal the ONLY: .4 . . , . . . . 1 .. . .. 1.Welt ConteactOr Information:. • 'w*Lte ADANDONitaNft0ETAILS . . . . . I— aL i • . . I I - • ., ,„rrr, Cif S 7a;For GepprobelOPT-or Closed-Loop Geothermal Wells having the same • - ' Well Con trietor Nali (ot Well ownii3persortally abandoning-Mill on Illsrhorpropeity) well eoustruction/dcptb,only t OW-317 is needed. Indicate'I'OTALNUMDER,of- 2/4-7 37'A -I:-- wells abandoned;, . I I! • , , '• . • ,* - -2 3 f• NC Weil Coatmeter Cenifiealion?Cooker 7b.Ap•proihnnte volume Of Water,reittainktg in well(s);, 2 L.' .(gal.) • • FrOa-tr C.:iA Ld6:f( tgiivy.Le . FOR WATER SUPPLY l,E1,-LS ONLY; '. • " • _eitMpatiy Name • .: 7e.Type of diiinfeetant used: 7-H .wen rniStriOiti.:Perniitiii-::.. 1 00 1 if 3q,'7, - • 'Listilltopidtealite rif,egion,Tinicilo00110 Ke..tlle County,Stale;Kiriahee.810(an own I n G., . • 74..Autourit efdhinfectitntinsedi.. -..; ,.. •f•-•.. •, 4._it.c11 use(check well •';',.2- , . . 1 . • Water stipolkwtot ' • --,..- • -' 7e.SealintMeterialsuaed(ChechafillMt apply)r • .,. .0Agticolteral . : c., tIlduiticipalftlilic Cl Neat Cement Grout ,,' •tienentonite Chips or Pellets :-.- OCteothennet(tieittia*COotit4SepplY) 421(eSidential Water Supply(single) .,1 Cl Sand Content Grout • : - .cl Dry Clay . . ,.blinitistrial/Commercial• :i:.• llitesidential Water Supply(Shared) C Conetelo4d9ut . Cl I)rili Cuttings • - ,- 6hstation • . . . • '....'''. . .. • • .. • -• ',-_13 Specialty Grout 0-Onozol ___ ________________ -- -----•..-Noti•-Witier Supply Well; - - ___ _ .. . _ __. _ _, _ el Benionite Slurry II Other(explain under 7g) tilVIOnitoring ----: . .. • •:': Oltecovery• • • • r i, • . -•lideetton'Welk' . -, - •- • •7f.For each material selected above,preside amount Of materials Used: • ..,,, bitnuifetIleehinge -,.,.• 1:1Cmundwater Rentediatien- . Z ZOO/IP 5 - . . 04quiferiteregs-anditecoveii• f.15tdinity Dania • -2 13Aiptifer Test : •••,..7;;;' CIStorinwater Drainage . .. . . • . . .. . • • , .- . . , .I3r.iperimental TeolitiOlogy,•;'•. 1:1SnliSidettr.e Control • 7g Provide a brief description of the abandonment procedure. OGeO.thernud:(Closed Lbo,p - pffracer. . • . iI Cl . • -• Otothennal 4liating/CoalitigReturn)- -ClOther(exylain inideilg) .51.64:4-),f, to'Y. ii.e•Gund • - • . ii,: , - 2.-9r -i 4.Dote well(s)abandoned:11 - ._.._ ' l' • MAX e 1 anz4 5a.Well location; ,.., , , 0 - -• . Harrl/e: //a/tferY:!.,i,!-.'lie U. c, -.--, : ' s. . : • .- ,- j..1.ic-,1 "c•'.7``‘`"'"le-',7Z1-1-)01- D4q0.1-30G iiyiOwneiltania• ..• .‘ .F,143111Yitt#•(itatiolicable) • fi-eertifications:.. 12-35 5 0 td...944-0,-.5-4,' ,'..t(q kci, Yvirier5tiille )142967g 141*0:Aattress.bit%att4741) .." ' . 0 1 1—7,6 1-011 Signatee1Ceitified' t'siell•Ceati*Ft'O.i.4.3. Well Owne. " Date, ' • /41?_,C:k,len bvrj Oil-736 f 04- : - ' By sig!thig.'thii fonni.Therebk Ortth that the well(s)was 6verei-abizndninyi In cpiuii*. ' ~. Parcel Pkeitificaikin No-(PIN) accatelanai will;ISA-tire-AC.026%0100 or 2C:02017rall Con,nitainteStindar-i _ . andthat a copy ofthtt cord/we beenpravIdedtothewell otOnee 51).-tatibule atatougiliithi5.0 digreeribainu(esisecomis or decimal degrees: - • " • • • • - OWeliAelke.se helices iisat*ent) _ • • 9.Site.dtagrant or addttional well details: - - • . , tre, You may Use*back Of this page to.provide additional well site details or well . ' • .' - ', 4.;-':. . .. '' abandonment.ditalli. You*faint-attach adtlitiPhal PageS if neCeSslity. cimi§littieroi*bET*04 008w14ist(Ittv6ABAtOop:ED --... .:Al fai;h401.0izsliiicOrretiotillsMayitilgbItt!Porihulhide kijedien4M water plyon- sow,elis 411BM1174141slitucTIO1,s ozytattheiod-ciostrinnoitobandomonit,you ealtIubmit vie firm: : •• 1i,,.4 Ida.For_ Welk:- Submit this form within 30 days of completion of well - -- 64.1yealikl: - • Ai Th 1 . . abandomnett to the following • ' . , . .„ .., Division of Water ReSources,fnformatiou Precessing Unit, 61).Total Well depth: . " 2 41 0 (ft.) . 1611 Midl.Ser4tti Center,Raleigh,NC276994.011 • '-' • 1 ... ,.. ••••• • •,10b,ger Jakketion Wells: Siltnuoition_le,sending the'form to the address in 10a . • . ,..... L--, . • .• 6e,Derekole diameter •••" - --) . (in.) above,also submit one copy Offthit,form within.30 days of completion of well .. , abandonmentto the following. i • •-- 4t1..Wttter level below g4iind surface: .7.--0 _ . ,(ft.) , Division ofWater Itesourees,",,, Undergreundtticellon clintrol-Progranh. , 1630'AAR Servici f.ente4 Ralel*NC 27699-1635 A 1.., i I • _ . 66,•outr!Okint length •(*known): /V/A . (ft.) • - He.For Witter Suitplv 84„ Infection-Wells:lit addition to sending Me-fonn to Ore . ., . . _. . etitess(cs)above also submit otia copy of this than within 3Q days of completion of well abandonment to the county health department of the county *hero g Iniior.4:isfpgIttibbig ko"gili(If Mow.* N/A. .(41.) • abandoned. . ,. ' '.....:..,. . . Og.IMieen length Of knOiiii): , A/IA . ...„. -. ' • �'EEL-` •'" -O ONM NT E C ORD- '/ For Internal Use ONLY: 1.Well Contractor Information: /�.3Aif WELL ABANDONMENT DETAILS Z7C- Ctes,S �, �5 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Well Contractor Na (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: a�-4 ', NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '4 (gal.) James Darby Well Drilling LLC FOR WATER SUPPLY WELLS ONLY: Company Name I' 7c.Type of disinfectant used: 2.Well Construction Permit#: ) 001 31 0Z List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 7d.Amount of disinfectant used: 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural ❑Municipal/Public eNeat Cement Grout i 0 Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout i, 0 Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings ❑Irrigation 0 Specialty Grout 0 Gravel Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g) ❑Monitoring ❑Recovery _ Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation f ' (_ ��/ K p ❑Aquifer Storage and Recovery °Salinity Barrier • 1 r1 _ 1 d� ❑Aquifer Test ❑Stormwater Drainage ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer I r�,4._ �Va t' k r, 4 • ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) . 61 OLJt.I� 1 ( ro re U (� • We Ctt T ' ICPIL7ljr,totr i f ..C.- " 4.Date well(s)abandoned: 'l 1 voe rip �1 I� ,^ 5a.Well location: M t�C "' ► .`L.:k'L .i v t Li i Octavio Laris MAR 0 1 2024 Facility/Owner Name Facility ID#(if applicable) 8.Certifica'on: 4817 Sadler Rd in'`o` 'DANC `` U'i� Z3 Physical Address,City,and Zip Signature Certified Well Contractor or Well Owner Date Mecklenburg By signing this form,-I hereby certin)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: i 1 (if well field,one lat/long is sufficient) 9.Site diagram or additional well(details: You may use the back of this page to provide additional well site details or well N W 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-water supply wells 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 Ili€• abandonment to the following: Division of Water Resources,Information Processing Unit, rr 6b.Total well depth: l C (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: 2 (in.) above,also submit one copy of this form within 30 days of completion of well abandonment to the following: i 6d.Water level below ground surface: t b (ft.) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 I 6e.Outer casing length(if known): (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 6f.Inner casing/tubing length(if known): (ft.) abandoned. 1,,,.. 6g.Screen length(if known): (ft.) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016