Gaston_Well Abandonment_20240710

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CM V C\P�yse. 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
We Contractor Name(or well owner personally abandoning well on his/her property) well constmction/depth,only 1 GWO is needed. Indicate TOTAL NUMBER of
Awells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Morgan Well & Pump, Inc. FOR WATER SUPPLY WELLS ONLY:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,'County,State.Variance,etc.)if known
7d.Amount of disinfectant used: 02
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout *$entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) b4 csidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier JJ
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geotherriral(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ("rq� \` :Lid rc "'eJ
4.Date well(s)abandoned:
5a.Well location: LeS'�-� ��� of G+t�� �\\,
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
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y1? s�Cc�nleyrS CtJ ��� 6 2oL`�
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certtfy that the well(s. tc.�were)"ab�o��
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 il•e)!4;n cltnn'&Yn
rr.l O �fl24G
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well J
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
JAI 36(S 5""] N .0 z-- ,,j W You may use the back of this page to provide addit}">"I Eft lefdllW411
abandonment details. You may also attach additional pages if i.ke
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For'All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: �� abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: o- 2�c (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:
1 (in.) above, also submit one copy of this form within 30 days of completion of well
f�1 abandonment to the following:
6d.Water level below ground surface: `w (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
61.Inner casing/tubing length(if known): (ft.) abandoned
bg.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016