Mecklenburg_Well Abandonment_20240610

WELL ABANDONMENT RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1. el Contractor I mahon• WELL ABANDONMENT DETAILS
Ii S M vw 7a.Number of wells being abandoned.
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
construction abandonment,you can submit one form.
7b.Approximate volume of water remaining in well(s): 7S (gal.)
NC Well Contractor CIMertification Number
FOR WATER SUPPLY WELLS ONLY: J
Company Name 7c.Type of disinfectant used: H t r /
2.Well Construction Permit#: )Qo' q `�'t,1� —
List all applicable well permits(ve.County,State,Variance,Injection,etc,)fknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑ Neat Cement Grout ntonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) JDAwrrdtto Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Z9y S
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ClCGCt kc, 3 ' r /t) xe
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: S >/12,4
5a.Well location:
Facility/Owner Name Facility IDk ifappli able) g•Certifies �aS(;
71'.YAiQfl dir'i: Li �Z, 21
,(N f 7
Physical
lAAdpdre City,and
Zip Signature o ertified Well Contractor or Well Owner Date
' R �1 n Zvi 1 � '^ By signing this form, 1 hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 01C.0100 or 1C.0100 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
vlr� You may use the back of this page to provide additional well site details or well
L4 36 N O y' W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLIS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same constrttctiorrabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: fy abandonment to the following:
�_
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
66.Total well depth: � (ft.)
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter v (in•) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 3 Q (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
I� (f�) 1Oc. For Water Supply&lniection Wells: In addition to sending the form to
6e.Outer casing length(if known): 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 abandoned.
6f.Inner casing/tubing length(if known): _(ft.)
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013