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Home My WebLink AboutMecklenburg_Well Abandonment_20240814 (9) WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT DETAILS �n f>� 11—�1 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the stone Well Contractor Nome(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of 0 so `l A wells abandoned: NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gall C-6 2 FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: 2.Well Construction Permit#: List all applicable well construction pennies(i.e.UIC,County,State,Variance,etc.)iflatowvt 7d.Amount of disinfectant used:_ 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural OMunicipal/Public Neat Cement Grout ❑Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay OlndusttiaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings ❑Irri ation ❑Specialty Grout ❑Gravel Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g) ❑Monitoring CLovery Injection Well: 7f.For each material selected above,provide 0wofint.of materials fusedC OAquifer Recharge ❑Groundwater Remediation ❑Aquifer Storage and Recovery ❑Salinity Barrier A U G G r ❑Aquifer Test OStormwater Drainage OExperimental Technology ❑Subsidence Control 1r,`�'.: q.` ''i U-1 7g.Provide a brief description of the abandonment PIRC a3 OGeothermal(Closed Loop) ❑Tracer OGeothermal(HeatingtCooling Return) ❑Other(explain under 7 ) �/ � ctep ►'1 C!/ 7"/I I,n �ru!"► 4.Date well(s)abandoned: 7—is Z l / lb t,. ,L 7,L 5a.Well location: G Facility/Owner Name Facilit ID8(if applicable) 8.Certification: Ord Hof GVG �� Physical Address,City,and Zip S' lure of Certified We Conttoctor or ell Owner Date TIP_C—ss G 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 Constnuction Standards 5b.Latitude and longitude in degrees/minutes/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: �� 27 N f�� ' 7 37� 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 DETAIIS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS Attach wzll construction record(s)ifavailable.Fornmltiple injection ornott-watersupply urlls ONLY uvith the scone cottstntctiott/abandortnteet,you can subrnit one fornt. pQ 10s. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#:LJ l7 D "� abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: _2 7 (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: 7. (ln,) 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- A) 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 of well abandonment to the county health department of the county where 6f.Inner casing/tubing length(if known): (fL) abandoned. 6g.Screen length(if known): (ft.) Form G W 30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 .t i A"AJ 4ai1171\LV1\111.1L'1r 1 XLVj%'%J1t)J For Internal Use ONLY: 1.Well Contractor Information: 1- / WELL ABANDONMENT DETAILS -JQ czb 2- 1(., �° 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Well Contractor Narne(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of wells abandoned: NC Well Contractor Certification Numbe 7b.Approximate volume of water remaining in well(s): (gal•) G t (� FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: 2.Well Construction Permit#: List all applicable it-ell construction permits(i.e.UIG County,State,Variance,etc.)((knouvn 7d.Amount of disinfectant used: 3.Well use(check well use): Water Supply Well: 7e.tSeallng materials used(check all that apply): ❑Agricultural ❑MunicipaVPublic eat Cement Grout ❑Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay ❑lndustriaVCommercial ❑Residential Water Supply(shared) ❑Concrete Grout Cl Drill Cuttings ❑Irri ation ❑Specialty Grout ❑Gravel Non-Water Supply Well: ss ElBentonite Slurry ❑Other(explain under 7g) ❑Monitoring 0 ecovery Injection Well: 7f,For each material selected above,provide amomM of materials used; -- ❑Aquifer Recharge ❑Groundwater Remediation ❑Aquifer Storage and Recovery ❑Salinity Barrier A U G 1 ?0 l 4 ❑Aquifer Test ❑Stormwater Drainage ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonmt4kt ❑Geothermal(Closed Loop) ❑Tracer ' ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) /17 e Cezrnen 1 n r��✓►1 4.Date well(s)abandoned: �S 1 CO G G Cie- Sa.Well location: Facility/Owner Name Facility Wit(if applkable) 8-Certitleation: 4SS 50 zgyo 7-IS Physical Address,City,and Zip 21ig of Certified ell C ntractor or Well Owner Date e L igning this fonn, 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 reco+rl has been prorided to the well owner. 5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: (if well field,one lat/tong is sufficient) 9.Site diagram or additional well details: •� � 3 Z G/ N '�0•�� 1-7 37s' 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 Attachwellcotistractiatrecords)ifavailable.Fornathipleinjectionortton-natet•supplvurlls ONLY trith the saute cotsirtictloit/abandonntent,you can subunit one fom+. 109. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#' ('A V JR — Jp_ abandonment to the following: ? Division of Water Resources,Information Processing Unit, 6b.Total well depth: 3 (ftJ 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Injection Wells: In addition to sending the form to the address in l0a 6c.Borehole diameter: Z (;n.) above, also submit one copy of this farm within 30 days of completion of well `` 2 abandonment to the following: 6d.Water level below ground surface• U ' y (1't.) Division of Water Resources,Underground Injection Control Program, v� 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): /V (ft.) 10c.For Water Suooly&Injection Wells: In addition to sending the farm 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 6L Inner casingltubing length(if known):_(RJ abandoned. 6g.Screen length(if known): Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 WELL ABANDONMENT RECORD �� Fat lracinill.WONI Y Thi.h,nn„ni be used for single or tndlipie wells I.Well(ronn•actr r InforniAtior: W'Fl.l.ABANbOTVMFNT DETAII ti Tyler Brown 7a.Number of wdls bring abandoned: 1 Well Conimice Nave for%ell o%ner persoruns ahankinag%en on hacAoco properic i For mnlnr"a nrtc"rvm or ]M•r-wafeY GsMpph Welts n,NLI -.0, .. c,7YtffINr1NW uh+u.i.ingyat,irJY rut.YhrMif rNre l,•�. 4625 NC W'allCoraraclar(:ciliftcalion Nanioat Tb.Apptoihnste t Marine or water remaiBblR it well(slp isal.l SAEDACCO FOR WATER St PPl 1 W FLIS ONLY: i oflvi tin Nxm 7c.'I\iK of di.infeclam aged: 2.Wdl C'onstrvctkrn Penrit o-70003214, , i • :::i,q;.i:::r,i, qi O lr•rmrtr n.e.t'wM.Vane.liinauor.11"Own,etc'.]ffAtn]Wu ?d.Aincwnt of disinfcctsnt uxd: 3.Well usr(check:well sae): Water Supidy Well; 7e.Sealing anateriAk Used(cbecic all that apply-): ❑Aimcultural ❑MumttpaUPublic 11 Neal Cement Cram M Bentontc Chips or Pelkts ❑ Geothermal IHcamng•'Coohall;Supply) ❑Rcsidemal Water Supph-Isingic) ❑ Sand CemnitGrout ❑Dn Clay ❑iridastrwl:Conmicicial 011cudennal Water Su;Vh isharod) ❑ C'oucrele Grout ❑Dnil Cuttings ❑Irri^thin ❑ Sp&nakv Grow ❑Gratel Non-Water Supph Well: ❑ Bentonite Slurry ❑Other(explain under 7g) i N10111onn¢ ❑keemm Inic-ctinn Well: X For each mativiild wiected chose.pmcide armiunt.if materials awd: ❑Aquti:r Rectutrge ❑Grouidnaier Remcdiation ❑Agtnkr Storage and Recm m ❑Salinity Banner Bentonite.:251b ,Wtr:gal. ifer❑Aqu iesl ❑SlonnwalerDr eainag - ❑Erpenntental i ❑Subsidence Control ' Prm idc s brief description of Ilk-abandnnukvni pnKcdum: ❑Geothermal(Closed l oopi ❑Tracer Q3ed Bentonite 0'-25' for abandonment ^.^ OGeothemtal(Hu"tnn �Coolin Rdum) l lOtticr(cc lam order '1 d,aft wellmAbandoned: 7-19-24 Ss,Wee kwation: U 1 Porry's Market Facilih''CMncr Nenr Facilah IT M orapplkabkl 6727 Wilgrove Mint Hill Rd. Mint Hill, NC 28227 / 7/19/2024 Ph,sisal Address.Ca),aid lip S wait of CCnifi 7d Wen(bnirxtcir ur We"O%m:t Mae --- Mecklenburg f3ty.eymtrjg An fFwsr, 1 Iterekb-cemA that Ae well(so was(weriel aiNvidoned at Coma) PaKd Meritfatbrr No.(PINI aa•onlasur wide 15.4 WAC O:C.0100 or X 0.1VX?Well Constmehon Semdards and that a crrpr oJthfa rrcrird Iran beery printieied to the well owner. Sh.Latitude and lo"Xitutle in dcareeslmiuutcsismads or decimal dettmev of%ell field one bi lnny n ullicieito 9.Site diagram or additional well nlctaft You mun me tie bast,of this page to pion de additional well site derails or well W' aba dountcm details You nun also attach aWin anal pages if nec:essan CO\S'tkl'(77ON DETAiLi OF W ELIAM BEING ABANDONED SUBMi ITAi.INSTRUCTIONS .itGieir wail c'rrarlriclrvnt n•enrel!s]{!uiwl]►4k•. hit milnpfr rnjre Oro ar rY]n-wvhr wpplr wefl,0.NLI'w]thrhr.atnircwrstrwr nabamknxnnir_iowcandhma,weP.-M l0a. For All Wchs, Suhmt thrc forni wilbin +0 dass of completion of dell 6a.Well!ID/8-2 abandoonient In the followin Diw4kin of Water Reamrcr,,Information Processing Unit. 1617 Mail Senior Cater,Raleigh.S( 276"4617 rib,Taal wdl depth: 25 (ft.) Imb.For Wellies Wdls In addition to sending the(unit to the adthem in lua otiose.also subunit one copy of this fonn within ;In dais of completion of isell ec,fkinholc diameter:1 (is,) abandonment to the fatbwing Disistesof WeerReaoorces,Underground Inimtiun Control Program. (,it,11 ater k eel below ;vnoral carfare: (flt,) 1636 Mad Senior Covarr,Rakish.,%C 2769946M 20 10c.For Water Sunwih & lnicctioo Wells: in addition to sending the form to Iic.()uhrcasiurlcn^nhiitl,nowni: (ftl the address(esl abcne. also submit our copy of ibis foam within 31) da)s of completion of well abandmunent to the count-, health department of the count) i.i.innerra.in_tabin�Irn�nh it Lmi%nr where*mndoncd tft.1 rig.s c ret,"knsth(If ri i s 5 (R.1 Fomn GW-.1n North Caaohaa Deparun n of Em monnred and Natural Rewaiees-Dh ision of Water Re sam cans Re,bed August Vi 1 i