Catawba_Well Abandonment_20230127 (10)

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WELL ABANDONMENT RECORD For internal Use"ONLY. j
1.Well Contractor Information: WELL ABANDONMENT•DETAltS
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Justin M a I IoWe 7a.For Geoprobe/DPT or Closed-La p Geothermal Wells having the same .
Well Contractor Narde(or well owner personally abandoning well on his/her property) Well coustructioiiMepth;only 1 GW-30 is needed. Indicate.TOTAL NUMBER of
4452=A. wells abandoned: ' I
15:8
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
S&ME, Ift. FOR'WATER SUPPLY WELLS ONLY:
.Company Name 7c.Type of disinfectant used:
2:Well Construction Permit#7 Not Ap p l i ba b l e
List all applicable,well constructitin permits(i.e:UIC,.Cotai State,:Variance,etc.)ifknown
7d.Amount of disinfectant used'
3.Well use(check well use):
Water.Supply Well:, 7e..Sealing materials used(cheek all that apply):
OAgricultural OMunicipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Ifeating/Cooling Supply) ❑Residential Water Supply(single). '❑ Sand Cement Grout. f ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared), ❑Concrete Grout I 0 Drill Cuttings
❑h'ri ation. ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: IN Bentoiiite Slurry O Other(explain under 7g)
!Monitoring ❑Recovery
Injection Well: 7h For each material selected above,provide amount of materials used:.
❑Aquifer Recharge ❑GroundwaterRemediation ;.. . Appcox. 1:6 gal.Quik=Grout used
❑Aquifer Storage and Recovery ❑Salinity Barrier.
[]Aquifer Test .. ❑Stormwater Drainage (55%of 1 50 Ib.bag of Quik?Grout)..
]Experimental Technology ]Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothemlal(Closed Loop) OTracer
❑Geothemxal.(Heating/Cooling Return) ❑Other(explain under 7g)' -
1,batch grout mix makes approkimeitely.30.gal. grout
pe''Quik-Grout specs: (1 50 Ib.bag alid 25 gal. water)
4.Datewell(s)abandoned: 1/6/2023 . : : Grout pumped.from bottom of well'using 1`.' tremie, ,
5a.Well location:- pipe until well is filled to-ground.surface or.aboVe.
Duke Energy Carolinas Not.A�pplieable
cility/OeNaie: + EH
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8320 NC=150, Terrelf, NC:2867.3 -
- JAN 2.'� .2Q2'3. 1/16/20.23:
Physical Address,City,and Zip - Signature ufCertified Well Contractor or Well Owner_ Date
Catawba 461803426350. �G;f �� �
By signing this form, 7 heby cerltye[�ylfmg�l(sf was'(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NC AC 02C.01C 0 200 Well Conslruclion 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:
35.6102136 .: . N -080.9715643 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 reeord(s)iliavailable.For multiple injection-or non-water supply wells
ONLY with the same construction✓abandonment,you can submit one form.
10a.'For All Wells: Submit this form Within 30.days,of completion of well ,
6a.Well 169.AB-8Q : . abandonment to the following: '
Division of Water Resources,Information Processing Unit;
100.0 .1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth:' (ff.) .
10b.For Infection Wells:'.In addition to sending the form to the address iti 10a
7.9, 4.9, 3.$ above,'also submit one copy,of this form Within 30 flays of completion of well',
6c.Borehole diameter: (in.)
abandonment to the following:
3.96 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground sntface: (lit.)
1636117si1 Service Cenfer,'Raleigh,NC 27699-1636
6e.Outer casing length(if known):
,1 I ,
$4.0.. 10c:For Water.Suunty At'Iniection Wells: in addition to sending the form to the
(lit.)
addresses)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): 95,0- (lit) abandoned.
6g:Screen length(if known): '5'0 (lit.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016