Mecklenburg_Well Abandonment_20240814 (7)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
1 a c,c��J L ��, f��� 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/deptb,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
17 J © 1 n wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
G 6 Z Ir X a10 FOR WATER SUPPLY WELLS ONLY:
Company Namc
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable urll construction permits(i.e.UIC,County,State,Variance,etc•.)ifknonvr
7d.Amount of disinfectant used:_
3.Well use(check well use):
Water Supply Well: 7ef ealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public lY Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential 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 MRecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:.
❑Aquifer Recharge []Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
I
❑Aquifer Test ❑Stotmwater Drainage _
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonYhteet- edure s
❑Geothermal(Closed loop) • ❑Tracer
❑Geothermal (Heating/Cooling Return) ❑Other(explain under 7 )
�_ ��Yl ('i<' I"'Pl7i r(
^7
4.Date well(s)abandoned: ! 45 Z�( A
G
5a.Well location:
Facility/Owner Name Facility ID#(if a plicable) 8.Certification:
If??/o S'Z
Physical Address,City,and Zip Signature
si ,Aftertifted Well Contractor or Well Owner Date
" " �'� By signing this fonn, 1 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 Consttvction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a cope of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) - 9.Site diagram or additional well details:
t3�/y�3��9 N _��� ? /7,� 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 urll construction record(s)ifavailable.Forrnahiple injection ornon-natersupply urlls
ONLY with the same constrttctiordabandonntent,you can submit one form.
,�y� Q 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:_l r r(1J' (� abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
/ 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 7 (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: /0• � (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 Sunnly&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
V
6f.Inner casing/tubing length(if known): � ^/ 0 (ft.) abandoned.
6g.Screen length(if known): V uv (ft.)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

VV JPJLL ADAAM11J rMMIN l KLUU" For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
b L `�
u 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
J-1vo/ wells abandoned:
NC Well Contractor Certification Numbe 7b.Approximate volume of water remaining in well(s): (gal.)
CG Z ( r dl FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction pennirs(i.e.U1C,Colin•State,Variance,etc.)ifknovtt
7d.Amount of disinfectant used:_
3.Well use(check well use):
Water Supply Well: 7e.&aling materials used(check all that apply):
❑Agricultural ❑Municipat/Public 'Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential 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)
W6onitoring ❑Recovery
Injection Well:
�I 7f.For each material selected above,provide amount of materials used;•... .
i . . �
[]Aquifer :—%. '.. ..Aquifer Recharge ❑Groundwater Re ediation •' '
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage _
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment proced*ft-
/
❑Geothermal(Hearin Coolin 4'Return) ❑Other(explain under 7 ) �7!x n e4�' C'L'rr�p n "n. !''-it-N o
4.Date well(s)abandoned: �'� ( t L
Sa.Well location: t�
Fncility/Owner•Narne Facility ID#(if applicable) 8.Certification-
�)3c� ; '� �d Clio t-10-1-�- 7f�Z>c�
Physical Address,City,and Zip Signal Certified Well Contractor or Well Owner Date
eG/� signing this fonrt, I hereby terrify that the well(s) was(were)abandoned in
County Parcel identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/tuinutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,
one lat/long is sufficient) ? 9.Site diagram or additional well details:
N —�� �'� 7cJ 2�' 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 SUBI4IITTAL INSTRUCTIONS
Altachtveliconsrrnetionrecord(s)ffavailable.For multiple injectionornon-water supply wells
ONLY with the same co stnucliott/abandannretn,you can submit one font.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: / /I �— abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: / (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection 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
f abandonment to the following:
/
6d.Water level below ground surface: 7 (n,) 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&Infection 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 casingltubing length(if known): (ft.) abandoned.
6g.Screen length(if known): /( 2 P (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

W bLL ABANIJUNMEN1' RECORD For Internal Use ONLY:
1.Well Contractor InfoJrmation: ) WELL ABANDONMENT DETAILS
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 OW-30 is needed. Indicate TOTAL NUMBER of
l 1-�C) wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
v G 2 'S_ xPt`(jcat t,C� �� FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.)iflarown
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 14`6eat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑Industrial/Cormmercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non`Ws;ter Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
04onitoring ❑Recovery -
Injection Well: 7f.For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier —
❑Aquifer Test ❑Stormwater Drainage -77777
_
❑Experimental Technology ❑Subsidence Control :
❑Geothernlal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment proc6date:
�/
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7 ) �'k n e� ce') e/1'7 _ : /1 4�✓•'
4.Date well(s)abandoned:
}• �J r C
5a.Well location:
Facility/Owner Name Fa'l'tD#(I applicable) 8.CertiHcatiOn:j
-f_
Physical Address,f ity,and Zip Signature of Certified Well Contractor or Well Owner Date
By signing this form, 1 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 Constnrction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude indegrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) _ 9.Site diagram or additional well details:
N —�O. 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 ire//construction record(s)ifavailable. For multiple injection ormon-water supplvurns
ONLY with the sauce canstnrctionlabandonment,yott call submit one form.
�7 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: /"f &J—/ abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: Z 5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
y 10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 'jam (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
round surface:
6d.Water level below g " (R) Division of Water Resources,Underground Injection Control Program,
_ ! ;�
1636 Mall Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
J of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 0 _/ (ft.) abandoned.
6g.Screen length(if known): f Y "2,3 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016