Iredell_Well Abandonment_20240423

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor I o : WELL ABANDONMENT DETAILS
"1
A 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having fTiefe4
Well Contractor Name(or well owner personally abandoniAg well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
3J J^ (,% 2 wells abandoned:
NC Well Co (ntraa or_/ fication Number 7b.Approximate volume of water retraining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
Company N / Q� (� 7c.Type of disinfectant used:
2.Well Construction Permit#: 49�17 - J Do / a
List all applicable well construction permits(i.e.U1C.County,State,Variance,etc.)lflatowa
7d.Amount of disinfectant used: d 1
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mu�nicipal/Pubiic 0 Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Ii3Residential Water Supply(single) ❑ Sand Cement Grout
Clay
❑Indutstial/Commercial ❑Residential Water Supply(shared) ;3'6oncrete Grout ❑ Drill Cuttings
ChTigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry O Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7£For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation L�
❑Aquifer Storage and Recovery ❑Salinity Barrier — /( d , /
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: r�
Sa Well IoestiO� Ile, //^^C /1
Facility/Owner Name ` Facility ID#(if applicable) 8.Certification
Physical Address City,and Zip V, _/__1
T / Sigaatute of Certified Well Contract r or Well Owner Date
r 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
Sb.Latitude and longitude is degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lar/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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)##available.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you ecm submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: AJA, ,t abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (fL) 1617 Mail Service Center,Raleigh,NC 27699-1617
�1 1� 10b.For Infection Wells: In addition to sending the form to the address in I Oa
6c.Borehole diameter. "` 1 (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: /v() (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): A (g,) 10c.For Water Suooly&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): 0/t a (ft.) abandoned.
6g.Screen length(if known): (n)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016