Catawba_Well Abandonment_20220614

WELL ABANDONMENT RECORD For Intetal Use ONLY:
11.Well Contractor Information: WELL ABANDONMENT DETAILS
G e�YYYx 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor N e(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
Z�Q ._1 �i� wells abandoned:
NC Well Contractor C-ertrtification Number' 7b.Approximate volume of water remaining in well(s): v (gaL)
e 14 Jc yoylce, )(fJ] )Jf a/l;24 1 Hti� FOR WATER SUPPLY WELLS ONLY:
Company Name 2
cc����••�� 7� 7c.Type of disinfectant used:��L •V b.V N_ J b
2.Well Construction Permit#: �
®S''�✓� '�Ij 1 V�
List all applicable well construction permits(ie.,UIC,County,Slate,Parlance,etc.)ifknomvn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Wen: 7e.Sealing materials used(check all that apply):
❑Agricultural OMunicipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
DGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
Olndustrial/Commercial DResidential Water Supply(shared) )4 Concrete Grout ❑Drill Cuttings
Olirigation ❑Specialty Grout ❑Gravel
Non-WaterSuppiyaWglC— Fti- t
p 1j Ir -,i ❑Bentonite Shiny ❑Other(explain under 7g)
DMonitoring [ - �`' ""5 DRecovery
Injection Wen: t 1 7f For each material selected above,provide amount of materials used:
OAquifer Recharge J U'`l " 2�ZGronndwater Remediation ��,- G -+
❑Aquifer Storage and Rew ���f3C.5� �i$arrier
OAquifer Test 1n10 � cVa1QJBC�3DStormwaterDrai
nage
OExperimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
DGeothermal(Closed Loop) DTraeer !`` `
DGeothetmal(Heating/Cooling Return ❑Other(explain under 7g) C�� I 1 l&_ r-.V 1.l 1,.� b, RDycl' V�
4A Gca,Y,e r„* from Fl �
4.,Date well(s)abandoned: C7 V ' k� t '�J `, 1` '
Sa.Well location:
Facility/Owner Name Facility lDil(ifapplicable) 8•Cesti6calion:
Physical Address,City,and Zip Signature of Certi ed Well Contmetor or Well Oviner Date
�-f�w1x, CA>��,lk-, 2b97o2�s`i�332
By signing This form,I hereby certify that the wells)was(xere)abandoned in
County Parcel Identification No_(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Statuldrds
56.Latitude and longitude indegrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/tong is sufficient) )) 9.Site diagram or additional well details:
p3 5 ( 35 i) N -11 Z W 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.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach%wit construction records)ifavailable.Formulliple injection ornon-uwersupph•wells
ONLY ivith the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a Well ID#6�����' `�33 abandonment to the following:
/ Division of Water Resources,Information Processing Unit,
6b.Total well depth: (� (ft-) 1617 Mail Service Center,Raleigh,NC 27699-1617
��I) 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: fin) 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,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(f lmown): A (fL) 10c.For Water Supply&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this fort within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing(tubing length(if known): h)1?q (ft.) abandoned.
6g.Screen length(If known): `t` (ft-)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016