Gaston_Well Abandonment_20230327

WELL ABANDONMENT RECORD For Internal Use ONLY
1.Well Contractor Information: WELL.4BANDONMENT DETAILS
K. Brandon Moore 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
2957-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
-.. - ---, - 7c.Type of disinfectant used: yp
2.Well Construction Permit#:
Lim all applicable well construction permits(i.e.UIC.Counry,State,Variance,etc.)jbtown 6 oz.
3.Well use(check well use):
MAR 2023 7d.Amount of disinfectant used:
Water Supply Well: 1 r.': ) 1?e.Sealing materials used(check all that apply):
❑Agricultural ❑MumcipaVPub&,'.i�.3 ❑ Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) SResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) C Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ 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 Concrete grout 2 cubic yards
[]Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/CoolingReturn) []Other(explain under 7 ) Poured concrete directly into well casing
and filled to top of casing which terminated
4.Date well(s)abandoned: 3/14/23
above surface grade.
5a.Well location:
NC DOT N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
5515 Wilkinson Blvd. � IZ,,P, ✓� �S?S7-A 3/14/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
MCAdenville, NC 28101 3585028292 By signing this form, 1 hereby cerrifyy that the well(s) was (were) abandoned in
County a.0 n Parcel Identification No.(PIN) accordance with i5A.NCAC 01C.0%00 or 1C.0100 Well Construction Standards
v 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.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.249594 N 81.074681 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 INSTR►TCTIONS
Attach well construction record(s)ifavailable.Formultipleinjectionornon-watersuppl)wells
ONLY with the some construction abandonment you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 225 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob. For Iniection Wells: in addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in) above,also submit one copy of this forth within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: Unknown (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
59 (ft.) l Oc.For Water Suooly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this forth within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): Unknown (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016