Catawba_Well Abandonment_20240529

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
NfY\�k 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Namc(or well owner personally abandoning well on hs/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor CerC6calion Number 7b.Approximate volume of water remaining in well(s):----t (galj
I ":Plrue�L FOR WATER SUPPLY WELLS ONLY:
Company NanU + C1( C , j
1l,, '' l' 7c.Type of disinfectant used: lIJ I 4Y�( Nt tK
2.Well Construction Permit#:WO C- 24oS I b--D
Listall applicable we/1 construction permits(i.e.U1C County.State,Variance.etc.)ifknokn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Suppy Well: 7e.Sealing materials used(check all that apply):
OAgricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
OGeothermal(HeatinglCooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑lndustrial/Commercial OResidential Water Supply(shared) D�CConcrete Grout ❑Drill Cuttings
❑Irri tion e"Specialty Grout�( o�G� k�Q/yte�,❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry`` Other(explain under 7g)
OMonitoring DRecovery
Injection Well: 7f.For each material selected above,•-provideamount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier O�
�- ❑Aquifer Test ❑StmmwaterDrainage MAY ', Li)
OExperimental Technology ❑Subsidence Control
7g.Provide a brief description ofltlt bAsid6nin�nt prdtWil*:.
EOGeotherrnal(Closed Loop) ❑Tracer N1 .
❑Geothermal(Heatin /Coohn Return) ❑Other(explain under 7 ) t r 1
Za-Z11,S n�
4.Date well(s)abandoned:
5(2 t z 1 .
5a.Well location:
Il�efry♦Casa l Scr!t i �� 3 T7/� Sa q?�$Z�
Facility/Owner Name t Facility IDN(ifapplicable) 8.Certification:
�5 3 reinG(_ �✓ nclu 4�
Physicality and Zip Signature ofCerti tcd Well ractor or ter
C e
Count By signllig this form, 1 herebv certify that the wells) was(were)abandoned in
y Parcel Identification No.(PIN) accordance with 15A NCAC 01C.0100 or 1C.0200 Well Construclion Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided 10 the wiel/owner.
(if well field,one IaVlong is sufficienr) 9.Site diagram or additional well details:
6 AS N gi 1 J.Ors� `v 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.
CONSTRU TION DETAILS OF WELL(S)BEING ABANDONED SUB<fITTAL INSTRUCTIONS
.Itiach xell roatrnrton record(s)ifarailahle. Forrmrltiple injerrion or rent-xorersnpplr rrrl(c
ONLY xilh Ik same conctrnetiwr/abanJonrnent,you ran submit onc•1orm.
Q 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: _Z40,510-a 1 ^� 5u�-R abandonment to the following:
i Division of Water Resources,Information Processing Unit,
6b.Totalwell depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
+7 �l 10b.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: L (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Nater level below ground surface: (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): _(ft•) 10c.For Water Sunoly&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(mown): abandoned.
69.Screta length(if known):
form GW-30
North Carolina Department of Environmental Quality-Division of Watch Resources Revised 2-22-2016