Iredell_Well Abandonment_20240514

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• WILL ABANDONAILLINITAkCORD For Internal UseDNLY:
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1.Well ContraCtor information:. WELL ABANDONMENT DET4ILS
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. .44 ILAN ti.„'.2.-1 hre...tn.C 1.- 5 ,.
7u.ForeoprObe/DPT or ClosetUoop Geothermal Wells having the same
Weil Contracter Name(Or viell owner Personally abandonin. given on-his/her propetty) well construction/depth,only I G1-30 is needed. Indicate-TOTAL NUMI3ER of-
• 2-4 7 34- :
. . . wells abandoned:
.NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):. - (gal)
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vt•o-rsa..$ GQ e-ck 1,-IP'Y'rvtio (-42 i . FOR WATER SUPPLY WELLS ONLY:
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• Company Name - . -'-•
.-. 7t.Type of disinfectant used;.. 1 CO p . .
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2.'Well Construtiontertitit iti: '4°Z-L4- 149 o 3 el - ,
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List all applicable ivellcpasizzid10r*imits(i.e.07.C,County,Stale Tratlance,eta)filmic&
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7d.Amountordisinfettent liked: , •• • . .
3.Well use(cheek well Use):
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Water Supply Well: •
• ' ••• • .7e.-Sealing materials used.(cheek all that apply):
.3AgriCultural- . • .0hfuniciPaiiitiblic .0 Neat Grout . : filliefitonite Chips or Pellets
., .C1Geothemial(fieating/Ceolint$upply). fiRreSidential Water Supply(single) CI Sand Cement Grout ,.. - • CI Dry Clay
.alnditstrial/Conintercial- •,-- •C1Residential Water Supply(shared) a Concrete Grout *• b Drill Cuttings
• .- , 131.1tigatien , . S
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• a Gravel
, • Noti-Water SitpjAY Well: ::-..
. li•Cil BP:lati6ini.tte°Shiny y
a Other(explain finder 7g)...
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CIMenitoring -- , • ,s'• -_______EIRecoveq-___ • - •
Injeelloo-Well: • - '.
. 71.For each material selected aliove,provide amount of materials used:
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bAquifer Recharge ',- aCtroundwater Retnediation• /7 5>1 L s . . . .
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•. : .. ciAquifer Storage and:Recovery OSalinity Barrier , . .....
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ClAnnifer Test . -... • aStormwater Etntinage
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aExperitnental Technology,--: . OSabsidence Control *
, 7g.Provide a brief description of the aba donment procedure;
.• OCte,otherinal(ClOsed-Loop)i.': .CITracer . . - ,. "
- CIGeothemial HeatinWCooling Retui
rn) DOther(explain Midair.7g) - . 3/iou.)ly. ,y ..
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ai -2.4.Date*elks)abandoned:-,-' . • •: . • .
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KAI •i ,.: L02I
5a.'Welliocation: -•- • -
Ch0.54;fy 6.1.111 Rk-
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Faellity/OViner Name !•: • F;aiilitylD#(iraPpileable) • 0:C.ertiticatkin: - 11-,c•C•.'• ow Qi30,0
• - ll 3CA;fn.h(Ly Ae,c.4.itiof/if poiasvivie AA_ .,281/7 . 74;4144.1. 1,0A...1.4.4.d 47-9.-2-1 f
Physical Address.City,and Zii,'''
Signitture'of Cettiffed Well Centractor or Well Owner Date •
By signing this form;Ihereby-leertifr that the well(s)-was(were)(.2bandoned in
counti •
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. PaicOlidei#46.000111°,(PIN)' aeconiance will:15140W 02C:0100 or 2C.0200 Well Constnietion.Standards.-
- d that a coi2y of this ilecord haS beenprovicled to the well oisner. . -.----..-. . •Sb..-I.;niitade andionglIndeln:degrees/minutes/seconds oidechnal degrees: • (-In. . • 1 ', •
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*6t*N't eld'onektik'ng s giflicleat) ' 9.Site diagram or additional well details:• • • .
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W You may use the back of this page to provide additional well site details or well
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abandonment detail.s. You may also attach-additional pages if necessary
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CONSTRUCTION DE*14A OF-WELLjkl BEING ABANDONED •
•SUBMITAL INSTRUCTIONS , • . . .
,,;.. 'Ned vggcAinstrithgoir recor01 ifaVailoble.FOrittulliple injedi6n or non-walemapply wear'
ONLY wills the same Onstructip0Mandonmint,you submit otiel9rm.
...". • . 10a.For An Wells: Submit•Ibis farm within 30 days of completion of well
6a.Well IDiti - ' Ai 1 4: •- •
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abandonment to the following:
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,Division of Water Reionrces;InformatiouPtocessIng Unit,. ..
6b..TOMI welldepth: .:'71(:, (ft.). " • 1617 Mail Service Center,Raleigh,NC 276994617
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- ,lob.For Infection Welk: In addition to sendingthe form to the addressaddressin 10a
6c.Borehole diameter: ::::l 2 . (in.) above,also'submit one copy of this form within 30 days of completion of well .-
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• abandimment to the following
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6d.Water level below ground surface: .30 . (ft.) Division of Water Resoulrees,Underground Injection Control Program,
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1636.Mail Service.Center,Raleigh;NC 27699-1636
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10e.For Water Supply&Infection Wells: In addition to sending the form to the
•• ft6e.Outer easing- (If-known): / ( .)
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address(es)above,also submit one copy of this loon.within 30 days of completion
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of well abandonment to the county health department of-the county Where
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6E100 citsing/itibing length(if known): • A)/1.t (R.) . -abandoned.
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6g.Screen length.(if kniain): At .4.- (ft.) •
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.. Form GW-30 . --