Catawba_Well Abandonment_20220815

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.W 1 Contractor Information: WELL ABANDONMENT DETAILS
��J�'�J 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sa e
Well Contra or Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is.needed. Indicate TOTAL NU L`R of
wells abandoned:
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NC IAontractor Certification Number 7b.Approximate volume of water remaining in well(,): _(gal.)
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a Q{. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: �!/��
List all applicable well construction permits 6.e.UIC,Coimo,,State,Variance,etc.)ftnomi O�
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply.Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Muni ipal/Public ❑Neat Cement Grout P-Kentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential 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 Su ,dct �••- ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ' >� 9 ❑Recovery
injection Well: v �� 7C For each material selected above,provide amountof materials used:
❑Aquifer Recharge pl��j t ❑OW undwater Remediation f, J
❑Aquifer Storage and Repoytep,C, PSaiinity Barrier v
❑Aquifer Test IrAcor, V r BOG ❑Stormwater Drainage
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❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description!of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ��� To /1
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4.Date well(s)•abandoned:
5a.Well to anon•
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Facility/OwnerName Facility iD#(if applicable) 8.Certification:
/P ysica�l Address,City,and Zip Signature of rtif ed Well Contractor or Well Owner Date
By signing this form,I hereby certo 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.
Sb:Latitude and loirgitude in degrees/minutes/seconds or decimal degrees:
(if well field,
one lam odg is sufficient) D Q 7 9.Site diagram or additional well details:
�7 jpZ N Q I/ J W You may use the back of this page to provide additional well site details or well
L abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION(DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructiorirecord(s)tfavatlable.For multiple injection or non-water supply wells
ONLY with the same cdpstnrction/abandonment,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, I
615:Total well depth:. (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
13e10b.For Infection Wells: In addition to sending the form to the address in 10a
6p:Burehble diameter: (in.) above, also submit one copy of this form within 30 days of completion o well
2 abandonment to the following:
6d.Water level below ground surface: �./ ({t) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e,Outer casing length(it(mown): (ft.) 10c.For Water Supply&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 where
6f,Inner casing/tubing length(if known): (it•) abandoned.
.6g.Screen length,(if known): y' l (ft.)
• Revised 2.2P-2016
Form OW,30 North Carolina Department of Environmental Quality-Division of Water ResoJrees