Catawba_Well Abandonment_20231204 (2)

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WELL ABANDONMENT RECORD Foi Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Daniel Summers same
7a For'Geoprotie/DPT or Closed(Loop Geothermal Wells having the
Well Contractor Name(or well owner personally abandoning well on his/her pmpeity)' well construction/depth,only 1 GW-30 is needed..Indicate TOTAL:NUMBER of
2579-p1-. wells abandoned:
NC Well Contractor Certification Number 7b.Approximate'volum 1.§0
e of wale i remaining in well(s):.. (gal.)
w.
Carolina Soil Investigations,ILC - FOR WATER SUPPLY WELLS ONLY:
Company Name
7c..Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i:e.UIC,,County,State,Variance,etc.)ifknotvn
7d.Amount of disinfectant used:
3.Well use(check well,use)c
Water Supply Well: 7e.Sealing materials used(check all that apply)
❑Agricultural '.. ❑Municipal/Public. a Neat:Cerhent Grout ❑Bentonite Chips or.Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) D Sand Cement Grout ❑Dry Clay
Olndusirial/Commercial Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
DIrri ation ❑Specialty Grouf. ❑'Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other,(explain under 7g)
NMonitoring '' ' ❑Recovery
Injection Well: " , 7L For each material selected above,provide,amount of materials.used:'
❑Aquifer Recharge ❑GroundwiterRemediation: neat Cell'leht 116 Ibs"(perwell)
13 itifer:Storage,and Racovery ❑$alinity:Barrier "
❑Aquifer Test ❑Stormwatei Drainage
DExperimental Technology. .. . :. ❑Subsidence Control f 7g.Provide a brief description o the abandonment procedure: '
❑Geothermal(Closed Loop) ❑Tracei
❑Geothermal(Heating/Cooling Return ❑Other( lainundei7g) trenlle'grOUted with neat Cement
4.Date wells)abandoned: 10-30-23. ..
5a.Well,location: !• Z023
Lenior'Rhyne.College " (Maintenance Bldg)
FacilityiownerName Facility ID#(if applicable). S.Certification: `..,. r•0
643'8th Ave NE Hickory, NC (L 10-30.23.
Physical Address,City,and Zip Signature of Certified Well Contractor or Well'Owner. Date
Catawba B signing this form,1 hereby certify that the wells was were abandoned in
. .
Y. Sn S f Y fY �) (were)
County Parcel IdentificationNo.,(PIN)'.' accordance with 15A NCAC 02C.0I00 or 2C.020t7 Well'Construction Standtirds.
and that.a copy of this record has been provided to the well owner.
.5b.Latitude an&longitude in degrees/minutes/seconds or decimal degrees: "
(if well field one 1aUlong is sufficient). 9.Site diagram or additional well'details:
35.74111 N 81.32446, w You may use the track of this page to provide additional well site details or well
abandonment details. You may also attach additiond'pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well.construcfion record(s)ifavailable.For.multiple injection or non-watersupply wells
ONLY with the same constructionlabaMonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a..We11ID#• MW-3 MW-4 abandonmentto the following:
Division of Water Resources,Information'Processin 'Unit,
6b.Total well depth: 40. (ft.) 1617 Mail Service Center,Raleigh;NC 276994617
lOb.For Infection Wella:, In addition to sending the form to the address in l0a
(2°Well) above;also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.)
abandonment to theffollowing:
.30 Division of Water Resources;Underground Injection Control Program,
6d.Water level below ground surface: (ft)
1636 Mail Service Center,Raleigh,NC 276994636
6e.Outer casing length(if known): n/a (fL)' loc.'F'or Water Sunift&Infection 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
6g.Screen.length(if known): rlf8 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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WELL ABANDONMENT:RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Daniel Summers . -
7a.For Geoprobe/DPT or ClosedgLoop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property)' well construction/depth;only-1 GWr30 is needed..Indicate TOTAL NUMBER of
2579-/4 wells abandoned: ? q 35
NC Well Contractor Certification Number 7b.'Approximate volume of water remaining in wdl(s):.. •80 (gal.)
Carolina Soil Investigations, LLC FOR WATER SUPPLY WELLS ONLY:
Company.Name. 7c.Type of disinfectant used:
2.Well Construction Permit#o-
List all applicable well construction permits(i.e.UIC,'County,State,Variance,etc)ijlototm
7d.Amount-of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑unicipal/Public S Neat.Ceritent Grout ❑'Bentonite Chips or Pellets .
❑Geothermal(Heatin)Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout. ❑Dry Clay'
DIndustrial/Commercial UResidential Water Supply(shared) ❑Concrete Grout' ❑Drill Cuttings
❑Irri anon ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
Mmonitoring ❑Recovery,
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroiindwaterRemediation neat Cement 101.5 lbS
❑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
❑ rn ❑[]Geothermal RetuOther(explain mder7g) trerrile grouted with neat cement =r.T•__
4.Date well(s)abandoned: 10-30-23: f 2023
5a..Well location:
'
infer, n ? i_;�,:,-
Lenior Rhyne College (Maintenance Bldg)
Facility/Owner Name Facility ID#(if applicable) 8.Certification: .
643 8th Ave NE Hickory., NC . 10-30-23
Physical Address,:City,and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba B signing this form,I hereby,cerii that the wells was were abandoned in "
y rm g f y 1y (J (Were)
County Parcel Identification No.(PIN), accordance with 15A NCAC 02C.0100 or 2C.0260 Well Construction Standdrds
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:
35.74136 N. 81.3242T �, 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 recard(s)ifavailable Formuhip1e injection or non-watersupply wells
ONLY with the same constructionlabandonment,you can submit one form.
16a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-1 MW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35 00 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Iniection Wells: In addition to sending the form-to the address in 10a
(2a Well) above;also submit one copy of this form within 30 days of completion of well
tic.Borehole diameter: (in.) abandonment to the following:
30 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface:. 00
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): n/a (ft,) 10c.For Water Suonly&Iniectioit 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.
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6g.Sere en length(if known): nlra (ft.)
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016