Catawba_Well Abandonment_20230127 (5)

WELL ABANDONMENT-RECORD For Internal Use OM.V-
1.•Well Contractor Information: WELL ABANDONMENT.DETAILS
Justin-Marlowe.
7a.For Geoprobe/DPT or Closed-I oop.Geotliermal Wells having the same ..
Well Contiactor Name(or well owner personally abandoning well on his/her property) well construotion/de0k only 1 GW-30 is needed. Indicate TOTAL NUMBER of -
wells abandoned:
4452-A
NC Well Contractor Certification Number 10.3
�+ 76.Approximate volume of water remaining in weB(s): (gal.)
S&M E,, Inc. FOR WATER SUPPLY WELLS ONLY:
Cempany.Name
7c.Type of disinfectant used: .
2:Well Construction Perini#: Not'Applicable-
List all applicable well construction permits fi.e:UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used. 1' ,
3.Well use(check well use):
Water,Supply Well: 7e.Sealing.materials used(check all that apply): '
OAgricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets /
OGeothemral(Heating/Cooling Supply) OResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
olnildstrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
-❑Irri ation ❑ Specialty Grout ❑ Gravel'
'Non-Water Supply Well IN Bentonite Shirty ❑Other(explain under 7g)
Monitoring Lixecovery.
Injection Well:. 7£For each material selected above,provide amount of materials used:
❑AquiferRecl*ke ❑Grotmdwaterkemediation. App[oX.,1.4 gal:QUik-Grout Used
ElAquifer-Storage and Recovery ❑Salinity Barrier.
❑Aquifer Test �$tortriwater lhainage (47%of 1 50 Ib.bag of Quik=Grout)
❑Experimental Technology OSubsiden'6 Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geotimetmal. eating/Cooling Rettir) ❑Other(explain under 7g) 1 batch grout mix makes zpproximately:30 gal..grout
per Quik-Grout specs. (1 50 lb. bag and,25 gala-water)
a.Date weu(s)abandoned: 1%6/2023'. ' Grout pumped.from bottom of well using,-V tre.mie.
5a.well location:: pipe until well is filled-to ground.surface or above.
Duke Energy Carolinas Not AppliCable -,' s ,� wgt_
Facility/Owner Name Facility ID#(if applicable) B.Certification: '?i"
.8320 NC-150i Terrell, NC 28673 - -�
JAN 2 7 2023 1/16/2023 .
Physical Address,City,and Zip Signature orcceifed well Cont6cior or Well Owner t Date
Catawba 461803426350. lnfcl�?�`i ��'r x._ lea
By signing this form,I hereby cer�r".1i .�1 vell(s) was(were)abandoned in',-
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standdrds
and that a copy of this record has been provided to the well owner.
56.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:
35.6139231 N -080.9733794 `l, You may use the back of this page to'piovide additional well site details or well
abandonment details- You may also{attach'additional pages if necessary.
I
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injeetion'ornon-watersupply wells
ONLY with the same construction/abandonment,you can submit one•form.
:. 10a.'For All Wellg:. Submit,this'form within 30.days.of completion of well
6a.Well ID# AB-13D abandonment to the following: ,
Division of Water Resources,Information Processing Unit;
86.Q 1617 Mail Service Center,Raleigh,NC 27699-1617
6h.Total well depth:= 00 �i
IOb.For Infection Wells:.In addition to sending the form to,the address in lOa-
10:0 4.8 above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.)
abandonment to the following:
6d.Water level below ground surface: (ft.)
2129 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
,I
77.0 10c:For Water.Suooty&Injection Wells: In addition to.sending-the fomi to the
6e.Outer casing length(if known): (ft.)
addresses)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): 81'0 (ft.) abandoned.
I I ,
4:Screen length(if known): 5.0
Revised 2-22-2016
Form GW-30 North Carolina Department of Envirommental Quality-Division of Water Resources