Burke_Well Abandonment_20240119

- WELL ABANDONMENT RECORD. For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
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Cody Dobbins 7a.For Geoprobe/DPT or Closed-Lop Geothermal Wells having the same
- Welt Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 1is needed. Indicate TOTAL NUMBER of
wells abandoned: I
4539-B
NC Well Contractor Certification Number 7b.Approximate volume of water i remaining in well(s): 940 (gal.)
Catawba Valley Engineering &Testing • FOR WATER SUPPLY WELLS ONLY: •
Company Name Household bleach
7c.Type of disinfectant used:
N/A,-see attached permit r
2.Well Construction Permit#: .
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)if known • r 2.5 gallons: • :
7d.Amount of disinfectant used:
3.Well use(check well use): .
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Water Supply Well: 7e.Sealing materials used(check all that apply):
- ❑Agricultural ❑Municipal/Public 0 Neat Cement Grout I 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 0 Sand Cement Grout Il IR Dry Clay. -.
• -❑lndustriallCommercial • ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation . e Specialty Grout ❑Gravel .
- — _ -• Non-Water Supply Well: - - ❑Bentonite Slurry ❑Other(explain under 7g)
- ❑Monitoring ❑Recovery .
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Injection Well:. . .. - . 7E For.each material selected above,provide amount of materials used: •
❑Aquifer Recharge ❑GroundwaterRemediation 38.0 cubic yards clean clay fill soil.. .
• • ❑Aquifer Storage and Recovery ❑Salinity Barrier . •
❑Aquifer Test ❑StormwaterDrainage 3.0 cubic yards ;' . grout
❑Experimental.Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop). ❑Tracer
Plumbing removed,disinfectant introduced,filled with clean clay soil to
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g) .
three feet below the surface and'a•soncrete ptug,was created to the surface. .
-12/22/2023 r ,._
4.Date well(s)abandoned: j, �.0 iLl2+ � ,�,
5a.Well location: • ` 'JP%Pi 1 9 2024
• Residence { •
Facility/Owner Name Facility ID#(if applicable) ' 8.Certification: ,,,. --....'3•%3 hAn
-100 Allman Street iOal '��'v
111512024
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Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner ' - Date
Burke . 1794669586
By signing this form, I hereby cert that the well(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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details: •
35.771120 N -81:707637 �, You niay 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 EN: N/A abandonment to the following: . •
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 84 (ft.) •
1617 Mail Service Center,Raleigh,NC 27699-1617
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lOb.For Injection Wells: In addition to sending the form to the address in 10a
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6c.Borehole diameter: 48 in above,-also submit one copy of this form within 30 days of completion of well
( ) abandonment to the following: 1
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6d.Water level below ground surface: (ft.)
74 Division of Water Resources;Underground Injection Control Program,
1636 Mail Service'Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): (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): (ft.) abandoned. !
6g.Screen length(if known): (ft.) •
Form GW-30 . North Carolina Department of Environmental Quality-Division of Water Resources; Revised 2-22-2016 .

Burke County Environmental Health
110 N Green Stntot Morgitnton,NC 211056(8n)764.9240 •
WELL ABANDONMENT PERMIT
tee edits far the Ahendont cat ofwells)
Owner: (A.%) L4 54, r
Adtbeso: too- AtivriA,1 , iic .z8/#55-• •
Pbone No.C3051 96 I- 5'087 " OTS#
AooeWèllSitLoestion: W. (7r$en St. gcl• r Los+
koi• Ti. 6e_16liki dive_ , 144,
BM Jti-vt oet ri)hf _ -
1),•pc of Well: ft4.1 -lot)
Diameter ot Well: Lig"
Abandoned Well site OPS coordinates
Weil To Be Abandoned Within 30 pays
Envirotosertal Health Specdelistinnst be preeent hefts sad&ides the entity proem orabendoomeat Ifyou
absaioa your well with out the Health Specialiet being palm;you will have to-to:cover the well
Abandonment Process to Be t( EgS 12.2.7F-rta• paw rills
• e-crift-r-e 4-e-phis
7Z-tsx
(V Ca If WLV4.4 aoly s
LOCATION OF ABANDONED WELL SITE SKETCH
fp Re.istevit. a.ttplawkittilsi _ittAty
&ktkilr 01:151-rux.-1-4NA C:cr.PAk
adot h46.-(e. Wei( 14)t4t. SagNis itadelloid illegtek
PRe.0.46ae. evs4as wet( 4D34 if 111.414 5 retake/Surese.,
V la ff ter .1404A Lakta Sktir4-•
ref/ toose:, e/-eafri eAy sot! darva.cl „ti•ritc.e
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abfd ei°"Pae-4" Ary PeAla/oakfl
Ctts .
) Pow( 6 44.,tik elmereft-plus ',7M7g;;.....°14:;**'•
I 44ec- e.oncrek plus kas 6veettcreiv
. %tacit
Set—up Qtit remaatil kola wegt. 504. fq(LS 4.,,,tveco-5t'S
lug la to rarefy that the private well for the Own(//Wilmot indicated above$114 fix the property well
'the Elute County Tax Mop Number thdieeied above his bean properly abandoned In acoordence with
the'Repair Complierbce Rime/se shown above _ _ _
zavi±1,W,At% to I 1;3
Reolth Specialist Date Abandentract Completion Issued
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