Catawba_Well Abandonment_20220607

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Alfred Kiesling Jr. 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Namc(or well owner personally abandoning well on his,'hcr proper-0 well construction/depth.onh I It,W-30 is needed. Indicate TOTAL NUMBER of
3266'A - wells abandoned: '
NC Well Contmctor Certification Numbcr 7b.Approximate volume of"a ter remaining in well(s): _(gal.)
B & K Well Drilling Inc FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:'Chlorine
2.Well Construction Permit#: U$- VZDa 1 — l 6o2 e2
Lur all applivablc r+r!1 com;neR on pc axis li.c. L'IC.(ouwv..)rwc,. !amon,c.:'t:.):f knoN'n
7d.amount of disinfectant used: G:c AC -5
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Ag icultural ❑Municipal/Public Er"�_eat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 21;reesidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Ind ustriaI/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout - ❑ Gravel
Non-Water Supple Well: ❑ Bentunitc Sluri-, ❑ Other(explain under ig)
❑Munitorinn ❑Recovery
Injection Well: 71'.For each material selected above,provide amount of materials used:
GAquiferRecharge ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑Salinity,Banner
LAquifer Test ❑Storm%131er Drainage —
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
!::Geothermal(Closed Loop) ❑Tracer A i
EGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) r 4�
e
1, fie
#.Date wells)abandoned: is 3 Z.� JU
h �01'1
- S
';a.Well location: a Es t e3£1 rViCYG
Facility/OwnerNalne U Facility lD=(ifapplrcable) 8.Certification:
*'IT l ;.1`.t..9oclo� it;�� c,t,,,'it, & V 5
Physical Address.City.and Zip denature a!'C ti:ied fell Contractor or w411 O++net Date
dx'. ��6197 1
Y Bt s;vnin�;his goon, !hereby'rer!tji thatio!00
relllr u'ns hrert;! abandoned it
County Pazcel Identification No.(YIN) ,coidwice with TJ!NC.4C U-'C.0100 or 9'ei%(01251rucrior:Standards
and?hair,coUr of tilts rei ord has been provided io the well on rtcr.
Sb.Latitude and longitude in degrees/minutesisecunds or decimal degrees:
(ifwell 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 abandonment dciaiis. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING AB.-DONED SUB Y11TT.aL INSTRUCTIONS
Ararcfr wcellcanwnretivn reeordici ifm'ailrhle. Far curltip/e irjecron ar!mx-varcr�;ryplr Hei(.+
ONLY with the same roncD'ucriardahondann!ent.tau::an submit one fain.
10a. For .all Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to ehc following:
C,� Q Division of Water Resources,Information Processing Unit,
6b.Total well depth: / O (ft.) 1617 I\lail Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: in addition to sending the form to the address in Wit
bc.Borehole diameter: (in.) above. also submit one copy of this form within 30 days of completion of w eil
abandonment to the following:
6d.Water level below ground surface: V (ft.) Division of Water Resources,Underground Injection Control Program,
1636 1tail Service Center,Raleigh,NC 2 7 699-1 636
6e.Outer casing length(if known): _(ft.) 10c.For Water Supply&Injecton N'ells: In addition to sending the torn to the
addre>st.e,)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.) ao.uidonea.
6g.Screen length(if known): (ft.)
Form OW-30 North Carolina Dcpm'lr.,cn!c"cr,cironmcntal Quality-Division afWarcr Resource; R,:0 cd'--2 1il6