Mecklenburg_Well Abandonment_20240403 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Con for In or k lion: WELL ABANDONMENT DETAILS
""r 4? /e_1 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 I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: I
NC Well Contractor 'fication Number 7b.Approximate volume of water remaining in well(s):
�� FOR WATER SUPPLY WELLS ONLY:
Company Name C(aA-'1 1
G Type of disinfectant used: /
2.Well Construction Permit#: ®d _11;L 7
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if mown L�®
7d.Amount of disinfectant used:
3.Well use(check well use):;
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑M cipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
[]Geothermal(Heating�Cooling Supply) Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) O'Concrete Grout ❑ Drill Cuttings
ClIrrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
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
13Experimental Technology ❑Subsidence Control I
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Re ❑Other(explain under 70 y' �9" LJ e 7 Li O/1 t'/'e
4.Date well(s)abandoned: -7 L
Sa.We locati u:
Facility/Owner Name Facility IDP(ifapplicable) 8.Certification:
106 Z�
Physical Address,City,and Zip Sigaawm of Certified Well Contractor or Alell Owner Date
t / By signing this form, I hereby certify 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:
(ifwell field,one lat/long is sufficient)
9.Site diagram or additional wIld'
etails:
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($)ifavailable.Formaltipleinjectionornon-warersupplywelLs
ONLYwith the same conaiructlon/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 6 n C abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth: (ft) 1617 Mail Service'Center,Raleigh,NC 27699-1617
I
10b.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: i
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6d.Water level below ground surface: (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service'Center,Raleigh,NC 27699-1636
6��
6e.Outer casing length(if known): A) lOc.For Water Suouly&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
6f.Inner casing/tubing length(if known): D (� (ft) abandoned. ;.i ,; ;;."; ?�•
6g.Screen length(if known): AQ (ft) !APR �r', 2024
ITlitli NJtiiC l Ar^, .t�::ly ug
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Dd Eel a 3c Revised 2-22-2016
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I
WELL ABANDONMENT RECORD For Internal Use ONLY:
I.Well Co orj(gj'ormation: WELL ABANDONMENT DETAILS
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 I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Co r Certification Nmnber 7b.Approximate volume of water remaining in well(s): (gal.)
G, FOR WATER SUPPLY WELL S ONLY:
Compaq Name n 7c.Type of disinfectant used: ! { `=/
2.WeIl Construction Permit#: l�lJ
List ail applicable well construction pe 1�C.County, Variance,etc.)#known 1�
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 ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) S d-ement Grout El Dry Clay
❑
❑Industrial/Commercial ❑Residential Water Supply(shared) Concrete Grout ❑Drill Cuttings
Oh-rigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
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❑Geothermal(Closed Loop) ❑Tracer 7g provide a brief description of the abandonment procedure:
[]Geothermal(Heating/Cooling Return) ❑Otht�er(explain under 7 ) (// t J C9(\L/'cam r
4.Date well(s)abandoned: 116 /d 1
5a.7,0
location:
v
Facility/Owner Name Facility ID#(ifapplicable) S.Certification:
0 (�,2 S- JI vk o s t� / /,,9d
Physical Address,City,and Zip Signatrue of ertified Well Contractor or Well Owner Daze
r
I-Ile G By signing this form, I hereby certify that the well(s) was (were)abandoned 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: II
(ifwell 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 WELDS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attachwellconstructionrecord(s)ifavailable.Formultiple injection or non-watersupply wells
ONLY with the same consiruct'on/abmrdonment,'you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 0 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 Iniection Wells: In addition to sending the form to the address in I Oa
6c.Borehole diameter: (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: /-/I (fL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service'Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (fL) loc.For Water Water Suppiv&Iniection Wells-Iniection Wells: In addition to sending the form to the
addres(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): r' (ft.) abandoned.
r
6g.Screen length(if known): ! D
APR 0 V 2024
Form GW-30 North Carolina Department of Environmental Quality-Division of Water ResoWc-es Revised 2-22-2016