Iredell_Well Abandonment_20240918

WELL ABANDONMENT RECORD For Intemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Alfred Kiesling Jr 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 1 GW 1I30 is needed. Indicate TOTAL NUMBER of
3266-A wells abandoned: I
P ;
NC Well Contractor Certification Number 7b.Approximate volume of water:remaining in well(s): (gal.)
B & K Well Drilling Inc FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorine
7c.Type of disinfectant used:
2.Well Construction Permit#:_oGqq oa 9 Jr SzT 3
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.)iflmown S(aM�
7d.Amount of disinfectant used: v
3.Well use(check well use): ,
Water Supply Well: 7e.Sealing materials used(check all that apply�):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout j�Beritonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) CResidential 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 ❑Recovery
Injection Well: 7f.For each material selected abov%provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation IN 15 /'(uC�
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage — A C o✓>.0-e T/
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g•Provide a brief description of the abandonment procedupe:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) �)( )f'e.1 L 'q.�V e
4.Date well(s)abandoned: ! c3 a a `'• �-.' ��ji
5a.Well location: SEP 1 b 2024
Facility/Owner Name Facility ID#(if applicable) 8.Certification: ��; t 0
99 S Fr--AL"k J V-,L) --3O-oZ
Physical Address,City,and Zip .Signature o ertified Well Contractor W et Date
�r1.LI � Gcl0-6� �O� By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.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:
N 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,.you can submit oneform.
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: (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
abandonment to the following: }
i
6d.Water level below ground surface: (ft.) Division of Water Resources,,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
6e.Outer casing length(if known): (ft,) 10c.For Water Sunaly&Iniec lion 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
6E Inner casing/tubing length(if known): (ft•) abandoned.
I
6g.Screen length(if known): (ft.) f 1
P i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i.
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Alf red Kiesl i ng Jr 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the saw
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
3266-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
B & K Well Drilling Inc FOR WATER SUPPLY WEL'LSONLY:
Company Name ;Chlorine
7c.Type of disinfectant used:
2.Well Construction Permit
List all applicable well construction permits(i.e:UIC,County,State,Variance,etc.)ifknown {
7d.Amount of disinfectant used: o�� s
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout E�-ffentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) AResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
01ndustrial/Commercial ❑Residential Water Supply(shared) 4H50—ncrete Grout ❑ Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation *X-244—
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Jaa
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 44-
q�
H.J
4.Date well(s)abandoned: / d 07 T P
5a.Well location: SF
Lim
Facciiility/Owner Name facility ID#(if applicable) 8.Certifrcation:
Physical Address,City,and Zip Signature oltertifieffWell Contractor o c e 15ate
4&36 lot. l'cs?9 By signing this form, I herebyA
' that the wells) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02100 or 1C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.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-
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 well construction record(s)ifavailable. Fornrultiple injection ornon-watersupply wells
ONLY with the same constructionlabandonment,you can submit one form.
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: (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: 60 fin.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:'
I
6d:Water level below ground surface �� (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing Length(if known): (g•) 10c.For Water Supply&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
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Rcsources Revised 2-22-2016
I
f