Iredell_Well Abandonment_20240529 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
I.Well Contractor Information: WELL ABANDONMENT DETAILS
Alfred Kiesli ng Jr 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
3266-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
B & K Well Drilling Inc FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorin e
7c.Type of disinfectant used:
Chlorine
Well Construction Permit#:_o2b�� - y?t{-J!9
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)ifknown /
7d.Amount of disinfectant used co"..-CV0
3.Well use(check well use):
[Non-Water
ater Supply Well: 7e.Sealing materials used(check all that apply):
PP Y)=
Agricultural ❑Municipal/Public Meat Cement Grout
�ntonite Chipsor•Pellgts
Geothermal(Heating/Cooling Supply) I>lResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay t rr
IndttstriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings MAY � '� (U24
Irri ation ❑ Specialty Grout p-C'ravel
Supply Well !f•` ;;:'; 'r _••
ry ❑ Bentonite Slurry ❑Other(explain undetf7g)❑Monitoring ❑Recove
Injection Well: 7f.For each material selected above,provide amount of materials used: '
❑Aquifer Recharge ❑GroundwaterRemediation Poured & Hydrated 5- c./
❑Aquifer Storage and Recovery ❑Salinity Barrier - ` ibL/lo,
❑Aquifer Test ❑Stormwater Drainage ID a D- 7&n o 1 �c fvu�t 1 A
❑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) L-C 0e, rm,>t I -0"Ao
lys 3C�
4.Date well(s)abandoned:
Sa.Well location: /
Faaciliit Owner'Name Facility ID#(ifapplicable) S.Certification:
Physical Address,City,and Zip
Signatur f Certified ell Contractor or Wei ner Date
U ytat��- G E- 9 I V By signing this form, I hereby cern at 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
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construcfion/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:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (fL) 1617 Mai!Service Center,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: fin.) 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: —(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): _(ft•) 10c.For Water Supply&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): (ft.) abandoned.
6g.Screen length(if known): (ft-)
Form GW-30 North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016