Gaston_Well Abandonment_20220909

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Todd Alan Costner 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
SUMMIT ELT, Inc. wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 52 (gal.)
NCWC 4168-B FOR WATER SUPPLY WELLS ONLY:
Company Name 3" chlorine tabs
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)ifknown 1 tablet
7d.:lmount of disinfectant used:_
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
Dirrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above.provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation concrete 3 cubic yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of IN abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
The well piping,pump,wiring etc.was removed prior to the abandonment.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
3"chlorine tablet was added, The well was completely filled with concrete.
4.Date wells)abandoned: 8/5/22
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Sa.Well location:
New Style Gastonia LLC }(n�
Facility/Owner Name Facility ID#(ifapplicable) S.Certification: J F O : Z l'LL
3011 S New Hope Road 7-, 8/12/22
Physical Address,City,and Zip Signature of Certified Well Contrao(br ner Date
Gaston 148738
By signing this form, /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.
56.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:
35014'6.86"N N 810 6'51.95"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 well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction abandonment,you can submit one form.
10m. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 38.7 (ftJ 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: 20 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.N'1'ater level below ground surface: 35.5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&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): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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¢-� , y Well Location f
35°14'6.86"M 81° 6'51.95 W
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Prepared BylDate:TC8/12/22
Site Plan Showing Well Location
3011 S New Hope Road Well Abandonment Laurel Trifecta Services
3011 S.New Hope Road 1722 Toal Street, Scale
SUMMIT Gastonia.North Carolina Charlotte,NC 28206 NTS
Source: Gaston CountyGIS Figure 1

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SITE Well Owner
Figure 2
3011 S.New Hope Road Well Abandonment New Style Gastonia LLC
1AM 3011 S.New Hope Road 2125 Southend Drive Suite 453 GIS
SUMMIT Gastonia,North Carolina Chartlotte,North Carolina
Source:
-.0.L pO""""c°"'°O'OI SUMMIT Project No.:4314.E0026 Scale:NTS

Well Abandonment—3011 S. New Hope Road SUMMIT Project No. 4314.E0026
Gastonia, North Carolina August 12, 2022
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View of well before abandonment
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View of well after abandonment