Catawba_Well Abandonment_ (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
-'C_Y'V-V-% se-rowu— 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Ane(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
Z,.in LI— R wells abandoned:
" 7b.Approximate volume of water remaining in well(s): 3
NC Well Contractor Certification Number 3 t5 (gaL)
Fir wt S V.V-4. L&JtX)r 1 l.V,k--T!=* FOR WATER SUPPLY WELLS ONLY:
Company N !� 7c.Type of disinfectant used: gko e k 1 c' Ct.. / �O
2.Well Construction Permit#: ��S�Zb22—d !_ILI 2.5
List all applicable well construction permits(Le.U1C,County,Stare,Variance,etc.)j/mmm
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Welb 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑lndusttial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑bTi ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stomrwater Drainage
❑Experimental Technology ❑Subsidence Control 7g_Provide a brief description oof'the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ll�
4..Date well(s)abandoned: — —'ZZ' a7 i
S1r.o L k l/�oy� �3
Sa Pow Well 9��►,l-DS'�.o�l�ly2SCtit�n,�,�
CAD 36�605Z°11z�5 ,
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
Physical Address,City,and Zip Signature of ee tied Well Contractor or Well Owner to
By signing this form,I herebt+cer1ifi+that the xell(s)was(were)abandoned in-
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0100 Well Con i Gctiorl>l da
and that a copy ojth(s record has been provided to the well oivnrerf AA b r ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,am lat/long is sufficient) 9.Site diagram or additional well details: 7
p ! t1 b ) )t :5+�siitK
/�35 yg j N Q�p 3y W You may use the back of thisy age to provide ad ditigna��yellas�i to o V lJ abandonment details. You may also attach additional .4
'nect �'-
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach nail construction record(s)ifmmilable.For multiple hyecnon ar•nan-water supply xells
ONLYwith the same consiructiaWahandonment,you can submit ane form.
t� 10a. For All Welk: Submit this form within 30 days of completion of well
6a.WellID(i �Sr�ZZ"�� ! -2S abandonment to the following:
��
Division of Water Resources,Information Processing Unit,
6b.Total well depth: o (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: ?q 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• v (ft.) Division of Water Resources,Underground Injection Control Program,
_1 t 1 1636 Mail Service Center,Raleigh,NC 27699-1636
tie.Outer casing length(if known): /V/ (ft.) 10c.For Water Suonly&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
6E Inner casing/tubing length(if known): /9 (ft.) abandoned_
6g.Screen length(If known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016