Mecklenburg_Well Abandonment_20240610 (4)

WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.WeA Contractor Inf motion: WELL ABANDONMENT DETAILS
7a.Number of wells being abandoned:
Well Contractor Name(or well owne personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
cf 3`-2,C— construction abandonmem,you can.rubmn one form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
0 ' rNAAXLS w+e/�')�j FOR WATER SUPPLY WELLS ONLY:
Companv Name ,
y 7c.Type of disinfectant used:
2.Well Construction Permit#: 10- 1
List all applicable well permits(i.e.County,State,i ariance,Injection,etc.)tf tnown 44
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout []Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) esidenual Water Supply(single) Sand Cement Grout ❑Dry Clay
[]Industrial/Commercial ❑Residential Water Supply(shared) [] Concrete Grout O Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry )t9'Met(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 711 For each material selected above, rovide amount f materials used:
❑Aquifer Recharge ❑Groundwater Remediation l J )b l�G/ rC �e.�..
OAquifer Storage and Recovery []Salinity Barrier
[]Aquifer Test OStormwater Drainage
OExperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer / 0'3� e
❑Geothermal(Heating/Cooling Return) []Other(explain under 7g)
4.Date well(s)abandoned: �Pm +,
5a.Well location:
Facility/Owner Name Facility iD#(if applicable) 8.Certific '72' J O N 1 O 424
`Z9 z3 �a•ras .�� c,�n�d�ly �1/L. �� �
irtF ,tie'►;^.,'1 �.t
Physical Address,City,and Zip ) 7 / Signature of e"ifie tractor or 1��t�V� ate
U�/ By signing this form, I hereby certify that the wells)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1SA NCAC 01C.0100 or lC.0200 Well Construction Standards
and that a copy of this record has been provided to the well turner.
Sb.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:
133 N '20. You may use the back of this page to provide additional well site details or well
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 injecitotr or rmn-uater supply
wells ONLY with the same construction abandonment,you can submit oneform. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well iD#• t• abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
--yy 10h.For iniection Wells: In addition to sending the form to the address in 10a
L 6c.Borehole diameter: _ (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: I ({t) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): �Y� _(ft.) iOc. For Water Suoniv& Injection 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
6f.Inner casing/tubing length(if known): (ft where abandoned.
6g.Screen length(if known): he (it)
Form G W-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013