Catawba_Well Abandonment_20230428 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Cody Dobbins 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-,36 is needed. Indicate TOTAL NUMBERof
wells abandoned:
4539-13
7b.Approximate volume of water remainin in wells Unknown al
NC Well Contractor Certification Number PP g O� (g )
Catawba Valley Engineering &Testing FOR WATER SUPPLY WELLS ONLY:
Company Name 12.5% sodium h ochlorite
7e.Type of disinfectant used: yp
2.well Construction Permit#: EHPR-03-2023-43699
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknoivn 1.0 liter
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay.
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation C 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 kr 1AN eda ��•.;
[]Aquifer Recharge ❑GroundwaterRemediation 2.5 cubic:yards
❑Aquifer Storage and Recovery ❑Salinity Barrier APR
D �O��
❑Aquifer Test ❑Stormwater Drainage H R
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonmentlb*je4rdgt'e`sn rf r:n&n q UNZ
❑Geothermal(Closed Loop) ❑Tracer DV 3
Plumbing removed,disinfectant introduced,filled with grout to sce
❑Geothermal(Heating/Cooling Return) ❑Other(explain under,7g)
4.Date well(s)abandoned: 3/30/2023
5a.Well location:
Piedmont Companies, Inc.
Facility/Owner Name Facility ID9(if applicable) 8.Certification:
2500 Startown Roads� wY 04/11/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 372119511871
By signing this form, I hereby certify that the tivel!(s) was (Were) abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 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/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.681716 N -81..272556 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
Atiachwellconstnictionrecord(s)ifavailable.For multiple ityection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one fornn:
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: Well-03-2023-192096 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 165 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (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: unknown (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In 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): (ft.) abandoned.
6g.Screen length(if known): (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016