Catawba_Well Abandonment_20240603

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well o jnttractoor Innf� c,"c orma �p WELL ABANDONMENT DETAILS
`cka-C l _'""" 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
/4',r 5— .9 wells abandoned:
NC W'•ell Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
A lco,u FOR WATER SUPPLY WELLS ONLY:f
Company Name T`��i-p 7c.Type of disinfectant used:� , /
2.Well Construction Permit#:
List all applicable well conxnvclion perhnits 6.e.UIC,Coun(v,State, Variance,etc.)ifkaown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mu pal/Public ❑ Neat Cement Grout entonite Chips or pellets
❑Geothermal(Heating/Cooling Supply) Q idential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑IndustrialriCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑irri gation; ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery I
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation
❑ 7 0 _�D /� �{J L& �f� C^at��
Aquifer Storage and Recovery ❑Salinity Barrier 7 �"'7
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothennhl(Closed Loop) ❑Tracer
❑Geothermal(1-Icating/Coolin Return) ❑Other(explain under 7 ) T J/��` Q_T i W�/ /
�'2`� E °L"�- �l• .i,If - l "'"_ )�� P/ � W�T/t �%'�N///`1�� l//t,SP"_
4.Date well(s)abandoned:
JUN lJ � 2024
Sa.Well location:/ ve`
acilily/Owner Name Facility ID#[if$pplic*S1j � •8•Certifi ton:
Ziyq jp'"-AS� A(W r
Physical
Address,City,and Zip Sign. ertified Well Contra for or Well Owner Date
co=- " 60— 37°LP 7 0IJ-1V By signing this form, 1 hereby certify that the tvell(s) was (were)"abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 w'2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitu,'e and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may ais-)attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Auuchwe!lcoustruc[iourerord(.rJi/irvui/able. Fornudripleinjeraianurann-u•atersupplYwells•
ONLY with the same constructiou/abandonmeal,You can submit one farm.
10a. For All Well : Submit this form within 30 days of completion of well
6a.Well 1D#: abandonment to the ollowing:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: )Cl (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
.F 6d.Water level below ground surface: Division of Water Resources,Underground Injection Control Program,
(ft.)
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.
6g.Screen length(if known): (ftJ
1
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016