Catawba_Well Abandonment_20230127 (11)

WELL ABANDONMENTRECORD Farintemal:UseONLY: j r
1.Well'Contractor Information: WELL ABANDONMENT DETAILS
JayLittle,' ;
. 7a.For Geoprobe./DPT or Closed-L'oop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property)' well construction/deA only 1 GW-30 is'needed. hidicate TOTAL NUMBER of
2717-A wells abandoned: 4 I G
NC Well Contractor Certification Number' 7b.Approximate volume of water remaining in well(s):
S 8t M E r•I n C. FOR WATER SUPPLY WELLS ONLY:
.Company Name "
7c.Type of disin fectant used: -
2:Well Construction Permit#: Not Applicable
List all applicable,w'ell constructionpermits.(i.e.VW,.County,State,YariancG eta)ifhnown
7d.Amount of disinfectant used:
-3.Well use(check well use): -
Water,Supply Well: 7e.Sealing materials used(check all that apply):
OAgricultural OMunicipal/Public ' : ❑Neat Cement Gioat ❑ Bentonite.Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
01ndustrial/Commercial ❑Residertial Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑lrri ation. ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: a Bentonite Slurry ❑Other(explain under 7g)
liMcnitoring ORecovery
Injection Well: .7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation APPfOX.,S gal,QUIk=GfoUt Used.
❑Aquifer Storage,and Recovery ❑Salinity"l3aaiei
❑Aquifer Test ❑Stormwater Drainage
(27%of 1.50 Ib.bag of Quik=Grout) -
OExperimental Technology. []Subsidence Control
7g.Provide a brief description of ttie abandonment procedure:
OGeothermal(Closed Loop) OTracer - . .. . . . . . .. .
oGeot>iemtai.(Ileat;ng/eoolingRetum) ootner(explain under 7g) 1 batch grout mix makes'approximately 30 gala-grout
per.Quik-Grout specs. (.150 Ib.,bag and 25 gal: water)
4.Date well()abandoned:abandone : 1 I18/2023
Grout pumped.from bottom of well using 1` trerriie: -
$a.weRlueation: pipe until well is filled'to ground surface or above..
Duke Energy Carolinas Not Applicable
Facility/Owner Name' FacilityID#(ifapplicable) 8.Certificationp �`
8320 NC-150, Terrell; NC 28673
• �� ..J,4N 2 .7
2023 1/23/23 .
Physical Address,City,and Zip Signature:of Certified Well Contractor or Well Owner. Date
Catawba 461803426350_ tni r-,TQ3la^,�1.i�L^.,c�� .�a t,rs
By signing this form, I hereby cerlijp the `11(9) was(were)abandoned in
County Parcel Identification No.(P119 accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and thdt a copy of this record h"as been provided to'the well owner.
5b.Latitude'and longitude in degrees/minutes/seconds or decimal degrees: i.
(if well.fie Id,one latllong is sufficient) 9.Site diagram:or additional well'details:
35.6052544 . . . N -80:9681414 W You may use the back of this page to'piovide additional well site details or well
abandonment details. You may also attach additional pages if necessary.-
CONSTRUCTION DETAILS OF WELL(Sl BEING ABANDONED . SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection ornon-water supply WI
ONLY with the same construction/abandonment,you can siibmf t one form.
10a. For All Well§: Submit this form within 30 days of.completion of well
6a.Well ID#: AB-48 L abandonment to the following:
Division of Water Resources,Information Processing Unit;
485 • 16171VIajl Service Center,Raleigh;NC 27699-1617
66.Total well depth: . {ft)
i0b.For Injection Wells:.In addition to sending the form to.the address in 10a ;
6c:Borehole diameter_.8.0 (ln.) above,also,submit one copy of this form within 30 days of completioa of well
abandonment to the.following: I
8.1 1 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) i
1636 Mail Service Center,Raleigh,NC 27699-1636
i •
i
N/A 10c.For Water.Subi6&Iniectio I Wells: In addition to sending the form to the.
6e.'Outer casing length(if known): (ft) 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):'38.S (ft.) abandoned. !
6g.Screen length(if known): 10.0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016