Catawba_Well Abandonment_20230127 (8)

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WELL ABANDONMENT RECORW For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAIIsS l
JayLittle.. . .
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same_.
Wbll Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth;only 1.GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
2717=A
NC Well Contractor Certification Number' 7b.Approidmate volume of water remaining in well(s): 2`2 (gal.)
S&M E,-in 0. FOR WATER SUPPLY WELLS ONLY:
Company Name l
7c.Type of disinfectant used: - }
Not-A• licable
2.Well Construction Permit#: p p I•
List aJJ applicable.well construcrion permits.(ie:WC,.Counly,State,;Variance,etc.)Jfknown
7d.Amount of disinfectant used: '
3:Well use(check well'use):
Water Supply Well:.' . 7e.Sealing materials used(check all that apply):
❑Agricultural' OMunicipal/Public • . ❑Neat Cement Grout `❑Bentonite-Chips or Pellets
❑Geothermal(Heating/Cooling Supply)' ❑Residential Water Supply(single)' ❑ Sand Cement Grout k ❑Dry Clay.
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout I ❑Drill Cuttings
Dhfigption. ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: a Bentonite Slurry ❑Other(explain under 7g)
liMonitoirng" . bRecovery
Injection Well:... - 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater-Remediation Apptox..3 gal.,'Qulk Grout Used
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑AquifetTest: ❑Stormwater Drainage (11%of 1.50 Ib,bag of Quik-Grout).
OExperimental Technology OSubsidence Control' 7g,Provide'a brief description of the abandonment procedure:
OGeothemmal(Closed Loop) ❑Tracer -t ; -
OGeothemmai.(Iieating/eooliagRetum) o Other(explain under 7g) 1.batch grout mix makes;approximately 30 gal.
:grout'
_ . 1 al per Quik•Grout'specs ( 50 Ib..bag grid 25 gal._water)
4.Dateweu(s)abandoned: 1/18/2023 : Grout pumped.from bottom of well using 1" tremie
5a.Well location: ground surface pipe until well is filled tog or-above.
Duke Energy Carolinas Not Applicable
Facility/Owner Name Facility ID#(if applicable) H:Certification: im. lbw.5 V
8320 NC=150; Terrell, NC 28673 ' ✓" JAU tl 2023. 1/23/23'
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 461803426350 i�It, i +�� '��'•�ti=. �1��:
By signing this form,I hereby'certifftvhM1&r_bg1(s) was(were) abandoned"in
County Parcel IdentificafionNo.(PIN): accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/secouds'or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram'or additional well details:
35.6052498 N 80.9681135-- W You may use the back of this page to provide additional well site details or well
abandonment details:,You may also iattach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED . SUBMITTAL INSTRUCTIONS
Attach well constructionrecord(s)ifamilable.For multiple injection ornon-water supply wells
ONLY with the same constructioWabandoninent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well .
6a.Well ID#• AB-4S abandonment to the following:
Division of Water Resources,Information Processing Uniti' .
2 .1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.) "
10b.For Iniection Wells: In addition to sending the form to the address imr 10a
6c:Borehole diameter. 8.0 (in.) above;'also-submit one copy of thii form within 30 days of completion of well .
abandonment to the_following:
7.64 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface:
1636 Mail Service Center,;Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A 00 16c:For Water.Supply&Injection Wells:ja 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 -
6f.Inner casing/tubing length(if known): 6.0 (ft.) abandoned.
6g.Screen length(if known): -15.0
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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