Mecklenburg_Well Abandonment_20240610 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well C?„ctorInform on: WELL ABANDONMENT DETAILS
�. (I` S YJa // 7a.Number of wells being abandoned:
Well Contractor Name(or well owner pe nally 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.
yx-'�_ 7b.Approximate volume of water remaining in well(s): �
NC Well Contractor Certification Number
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\PJ-.Q V FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: bird
2.Well Construction Permit#: V ' ( � I
List all applicable well permits(i.e.County,State,I'artance,Injection,e1cJ ifbrown 7d.Amount of disinfectant used
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑ Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) URcsiQential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 46<5­nc rete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well 7E Fof each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation ,
�i�_
❑Aquifer Storage and Recovery ❑Salinity Barrier �t
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonmept procedure,
❑Geothermal(Closed Loop) ❑Tracer ! KAJ?<' i t ' `'t J04
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) —.,/ ' 10 1✓v
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4.Date well(s)abandoned: Z a J z L/ ee)•,co,Q��
5a.Well location:
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Facility/OwncrName Facili IDl1(ifapplicable) g• rtifi o
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Physical Address,City,and Zip Signature of r ell Contractor or Well Owner Date
'mack i A&( 13_� •(DI2-1 q
BY signing this form, I hereby certify that the well(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 weli owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) �j 9.Site diagram or additional well details:
3 153��- ` G• � 0-1
N WYou 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)if available. For multiple injection or tort-water supply
wells ONLY with the same conrtruction'abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID#: _
quo Division of Water Resources,Information Processing Unit,
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6b.Total well depth: -1 w (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter (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: 30 (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
1Oc. For Water Supply& Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): N (ft-) 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): 1%it (ft)
Form GW-30 North Carolina Deparunent of Environment and Natural Resources-Division of Water Resources Revised August 2013