Mecklenburg_Well Abandonment_20240610 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well CCgctor Information: WELL ABANDONMENT DETAILS
.�` t �1 7a.Number of wells being abandoned:
Well Contractor Name(or well owner4ersonally 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.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
J
W W lLU FOR WATER SUPPLY WELLS ONLY:
]j }
Company Name ) 7c.Type of disinfectant used: 11 7 e
2.Well Construction Permit#:
List all applicable well permits(i.e.County,State,1 ariance,Injection,etc.)if known 7d.Amount of disinfectant used: �(/T f
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Munici aal/Public ❑ Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Itri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry to er(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation �Cyz�la��� L 'eV
❑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 / Naq
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) OPT //��
/ «t Sim TJ
4.Date well(s)abandoned: �(MZJ/74 F.
53.Well location:
Facility/Owner Name Facility tD#(if applicable) g'C ti ti
pao� IniOrxl"en A-rrapp„I Z? 2
Physical Address City,and Zip p-� Signat ert Well Contractor or Well Owner Date
�•P 114 1 N/ f d / Q 51� ' 0 By signing this form, I hereby certify that the ivell(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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) .p 9.Site diagram or additional well details:
/ —y p / W You may use the back of this page to provide additional well site details or well
�`Jj abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Anach well construction record(s)if mwilable. For multiple injection or non-water supply
wells ONLY with the some construction abandonment,you can submit one farm. 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: %v (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
IOc. For Water Supply& Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): P (ft.) the address(es) above, also submit one copy of this form within 30 days of
^/l completion of well abandonment to the county health department of the county
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013