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Home My WebLink AboutGaston_Well Abandonment_20220708 f WELL ABANDONMENT RECORD For Internal Use ONLY: I 1.Well Contractor Information: WELL ABANDONMENT DETAILS I Jeffrey Grant 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 I GW-30 is needed. Indicate TOTAL NUMBER of 4328-B wells abandoned:one k NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '3 (gal.) JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY: Company Name 2.Well Construction Permit#: WM0301213 7c.Type of disinfectant used: List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)if known 7d.Amount of disinfectant used: 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential 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) -EMonitoring- - - - ORecovery 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 ❑StormwaterDrainage Bentonite 50 pOUndS ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) Fill the entire length of the borehole with bentonite. 4.Date well(s)abandoned: 6-13-22 5a.Well location: Maplewood Gardens JIT Facility/Owner Name Facility ID#(if applicable) 8.Cer nation: u 2222 Glenwood Drive, Gastonia, 28054 Proc �9 0kvcyB0x3 6-13-22 Physical Address,City,and Zip Sign me of Certifie Well Contractor or Well Owner Date Gaston By signing this form, I hereby certify that the wells) was (were) abandoned in County Parcel Identification No.(PIN) accordance with 15A NCAC 01C.0100 or 2C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifweil field,one lat/long is sufficient) 9.Site diagram or additional well details: 35.259385 N 81.138406 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 well construction records)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#: GW-4 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 40 (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: 1.5 (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: 32 (ft) Division of Water Resources!Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 I 6e.Outer casing length(if known): 35 (ft) lOc.For Water Suooly&Infection 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): (ft,) abandoned. 6g.Screen length(if known): 5 (ft) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 f CE � I WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT DETAILS Jeffrey Grant 7a.For Geoprobe/DPT or Closed4 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 4328-B wells abandoned:Th,- NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 15 (gal.) JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: 2.Well Construction Permit#: WM0301213 List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used:, 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural ❑Municipal/Public ❑Neat Cement Grout S Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings ❑Irrigation ❑ Specialty Grout ❑Gravel Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g) eMonitoring - ❑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 ❑StormwaterDrainage Bentonite 50 pounds ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer ❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g) Fill the entire length of the borehole with bentonite. 4.Date well(s)abandoned: 6-13-22 C E F VED 5a.Well location: Maplewood Gardens II llr-�eT��i' Facility/Owner Name Facility ID#(if applicable) 8.Certification: nfa;tira^`can Proc�irtg Unk 2222 Glenwood Drive, Gastonia, 28054 , Q/rSoG 6-13-22 Physical Address,City,and Zip Signa e o ertifie ell Kontractor or'Well Owner Date Gaston ' By signing this form, I hereby certify that the well(s) was(were) abandoned in County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner. 5b.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: 35.259385 N 81.138406 ,i 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 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#: GW-1,2,3 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 36 (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: 1.5 (in) above,also submit one copy of this form within 30 days of completion of well abandonment to the following: i I 6d.Water level below ground surface: 32 (ft,) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Ce"nter,Raleigh,NC 27699-1636 i 6e.Outer casing length(if known): 32 (ft.) 10c.For Water Sunoly&Infection 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 6f.Inner casing/tubing length(if known): (ft.) abandoned. 6g.Screen length(if known): 4 (ft.) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016