Catawba_Well Abandonment_

WELL ABANDONMENT RECORD
For internal Use ONLY:
I.Well Contractor Information: WELI.ABANDONMENT DETAILS
KEN JOHNSON
7a.For Geoprobe/DPT or Closed Loop Well Conl Geothermal Wells having the sContractor Name(or watt owner personally abandoning well on his/ property) well construction/depth,only I GW,-30 is needed, indicate TOTAL NUN1131 R of
2608A wells abandoned:
NC Well Conunaor Certification Ntanber 7b.Approximate volmne of water remaining in well(s): (gal.)
AIR DRILLING INC FOR WATER SUPPLYWELLS;OONLY:
Company Name H I H
Z.Well Construction Pcrmilll:
09-2022-181126 7c''I'yPe of disinfectant used:
Lis(all applicable well consn•thcilon permits(i.e.U1C,Cotoay,State, flarlance,etc.)!!'known
3.Wc11 use(check well use): 2 CUPS
7d.Amount of disinfectant used:
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ® Bentonite Chips or pellets
❑Geothermal(Healing/Cooling Supply) PiResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri gation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry❑Monitoring ❑Recovery ❑ Other(explain under 7g)
Injection Well: If.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediatioh 50 BAGS
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stortwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(11cating/Cooling Return) ❑Other(explain under 7g) POURED 5Q BAGS B E NTO N I TE CHIPS
11-18-2Q22 . ,.
4.Dale well ,�
s)abandoned: �-�l�i,�.=
5a.Well location: 4! LUL3
BLUEFIELD BUILDERS
Facility/Owner Name Facility ID9 01'applicablc) er cation; )ftkvbnx"4``DI'l PrM.—A��:N)Url�
9101 CLEMENTS CIRCLE,TERRELL,N.C. 28682 411-8-2022
Physical Address,City,and Lip Signnture ofCcrtified ell Contractor or Well Owner Date
CATAWBA 462705089729
lip signing this forin, l hereby cerliiji,that lire ivell(s•) it-its (were) abandoned in
County Parcel identification No.(PIN) accordance with 15A ArCAC 02C.0100 or 2C.0200 Nell Collsll'((clioll Slan(lulYls
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy q/7his record has Neen provided to the well otwter.
(il'well field,one Intdong is sufficient). 9.Site diagram or additional well details:
35 0
35.952 N 80- 56.923 , You may use the back of this page to provide additional well site demils or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DLTATLS OF WELL(S)BRING ABANDONFD SUBMITTAL INSTRUCTIONSBrach1witconstrardonrecorrl(s)iJ'available. Rornn/l(ipleiyectionornan-wrr(crsty�plv,vells
0A9.Y with the Sant•ennsli•ticlioitlabandnnntenl,you can sidinat oneJorut.
10u, For All Wells: Submit this Form within 30 days of completion of well
6tt.Well ID/h abandonmen(to the following:
Gh.'I'olal well depth; 125 Division of Water Resources,Information Processing Unit,
(ft.) 1617 Mail Service Center,Ralcigh,NC 27699-1617
Gc,Borehole diameter: 6 lob. For Injection Wells: In addition to sending the florin to the address in IOa
(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: .) Division of Water Resources,Underground Tnjection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
l
6e.Outer casing length(if known): (ft.) 10c.For Minter Sunniv&inieclio'n Wells: in addition to sending the form to the
address(es)above,also submit one,eopy of this form within 30 days of completion
of well abandonment to the county health department of the county where
Gf.Inner casing/tubing length(if I:novn); (ft.) abandoned,
6g.Screen length(if known): (ft.) i
Form GW-30
North Carolina Dcpnruncnt of Gnvironmcntnl Quality-Division of Water Resources Revised 2-22-2016