Catawba_Well Abandonment_20230428 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Cody Dobbins 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-30 is needed. Indicate TOTAL_NUMBER of
4539-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 323 (gal.)
Catawba Valley Engineering &Testing FOR WATER SUPPLY WELLS ONLY:
Company Name :125% sodium h ochlorite
7e.Type of disinfectant used: yp
2.well Construction Permit#: EHPR-03-2023-43699
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknoim 1.5 liters
7d.Amount of disinfectant used.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Muuicipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay.
❑Industrial/Commercial OResidential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation S Specialty Grout ❑ Gravel _
-Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery `�T!�
Injection Well: 7f.For each material selected above,provide amoutft f$nat,,wG4dk/
❑Aquifer Recharge ❑GroundwaterRemediation 8.5 cubic yards 9
[]Aquifer Storage and Recovery ❑Salinity Barrier 404
❑Aquifer Test ❑Stormwater Drainage _
❑Experimental Technology ❑Subsidence Control 11^^�,,11e r v LJr4
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedtPeU,a'0G
Plumbing removed,excavated top 4'plus 1'buffer around well,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
introduced disinfectant,filled with grout,created plug at ground surface.
4.Date well(s)abandoned: 3/30/2023
5a.Well location:
Piedmont Companies, Inc.
Facility/Owner Name FacilitylD#(ifapplicable) 8.Certification:
2500 Startown Roads 04/11/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 372119511871
By signing this form, 1 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 record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 9.Site diagram or additional well details:
35.681486 N -81..272354 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
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells.
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells:. Submit this form within 30 days of completion of well
6a.Well ID#: Well-03-2023-192097 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 46 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: 30 (in) 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: 35 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 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'
6f.Inner casing/tubing length(if known): (ft.) abandoned.
i
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016