Gaston_Well Abandonment_20240814 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
or
I �t7 m �/k 1 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
/ '5 10
r C wells 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:
Company Name `�(�,n V'1 Gh I Q r f I�
7c.Type of disinfectant used:
2.Well Construction Permit#: 12 �'r�_
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown J V
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that appI ):
❑Agricultural ❑M icipal/PubEc ❑ Neat Cement Grout entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑lndustriaYCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g) .
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provideaamount`oftnaterials tised:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier vl /1 ('/� ✓✓✓ —tau�� 1 ( ,t�r
[]Aquifer Test ❑Stormwater Drainage �3 o /V
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:- J
❑Geothermal(Closed Loop) ❑Tracer rn I! p
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: —6;6—0�y
Sa.Well location:
(C Val MMd
Facility/Owner Name Facility ID#(if applicable) 8.Ce fication•
�a g b Id 1V t - of= L66P hall A-. N� E 2 2LJ
Physical Address,City,and Zip /� Si lure of C ified Well Contractor or Well Owner Date
��" By signing this form, I hereby certify that the well(s) was (were) abandoned in
C ty Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0.100 or 2C.0100 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.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:
a IV3S You may use the back of this page to provide additional well site details or well
Ll& N ` �J W 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 some 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:
1
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
(' 10b.For Injection 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:
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
�l 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)ll� address es above also submit one co of this form within 30 days of completion
address(es) PY Y P
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):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016