Gaston_Well Abandonment_20221114

WELL ABADMONME Y RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1. V V\Contract Information: WELL ABANDONMENT DETAILS
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- � 7a.Number of wells being abandoned. .
Well Contractor Namc(or well wncr personally abandoning well an his/her property) For multiple ityeciiou or non-hater supply inells ONLY with the some
construction/abandonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): / /� (gal.)
1 l�S(\ FOR WATER SUPPLY WELLS ONLY:
Company Name ��))
7e.Type of disinfectant used: ! /7
2.Well Construction Permit;#:
List all applicable nrell permit(i.e.Counhe State,Variance.Injection,etc.)tfknoum 1
7d.Amount of disinfectant used:_ W+✓�
3.Well use(check well use): —
Water Supply Well: 7e.Sealing materials used(cheek all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothenmal(Heating/Cooling Supply) LF._R6;—idetttial 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)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 2 LDS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer z t
❑Geothermal(Heating/Cooling Retunm) ❑Other(explain under 7g) "xe�' 7�� 3 1-11a C;-10�q d f C-A
9(Z412�— sty d— -; ll>� �✓ C'o>�e ��
4.Date wells abandoned: 11
14Sa.Well lacatio t: NOV 14 2022
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Facility/Owner Name Facility iD9(ifapplicable) S.Certifica ' '}tiGFFti�:iOD Pt.^C; nla Vfi1
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Physical Address,City,and Zip Sig e o erti ed Wel Contractor or Well Owner Date
By signing this foray, I hereby cent ,that the 1-11(s)-as(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 NCAC 02C.0100 or 2C.0200 11'ell Construction Standards
and that a copy of this record has beer:provided to the hell owtrer.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fat/long is sufficient) 9.Site diagram or additional well details:
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/ q r 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 R•-ELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach hell consiraction records)rf m•ailable. for n uhiple iiYuction or non-crater supply
trclis ONLY uYth the.mmne coyrsa7tctiorm%abatrdormtettr,yott can submit one fora r. 10a. 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: �S (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in I Oa
above,also submit one copy of this form within 30 days of completion of well
Gc.Borehole diameter: (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
r 6d.Water level below ground surface: (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
n ,, 10c. For Water Supply& Iniectiurt\Fells: In addition to sending the form to
6e.Outer casing length(if known): r 41 (ft•) 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 counn
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6C (Inner casing/tubing length if known • ft) where abandoned.
6g.Screen length(if lmown):_ :A& (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013