Gaston_Well Abandonment_20230428

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Billy J. Payne Jr. 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-30 is needed. Indicate TOTAL NUMBER of
4532-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): �0 (gal.)
I
Excel Civil and Environmental Associates/SRP Environmental FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: Chlorination-Ca(OCI)2
2.Well Construction Permit#: n/a
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iifknown 8-oz.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing mate iaTs is Oaf!
❑Agricultural ❑Municipal/Public El Neat Cement o t�-' �// 4. tonite Chips or Pellets
i
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement GrouAPR2 2023 ❑Dry Clay
s9
❑lndustrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Gidoorrwon Prncoewg ffjtfavel
Non-Water Supply Well: ❑Bentonite Slurry MWOOG ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete 29,000 lb
❑Aquifer Storage and Recovery ❑Salinity Barrier
6 ❑Aquifer Test ❑StormwaterDrainage Bentonite Pellets 150 lb (+/-)
❑Experimental Technology El Subsidence Control 7g•Provide.a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Eight 1-oz of tablets of chlorine disinfectant tablet was dropped into
the bottom of the 36"riser well&Bentonite pellets were poured into the
4.Date well(s)abandoned: 04/17/2023 well to near the TOW&+/-15 cy of Concrete was tremied into the well to
5a.Well location: above the top&surrounded 3-ft the outer stone to create a slab lid on top.
309 Weselyn Drive n/a
Facility/Owner Name Facility ID#(if applicable) S• cation:
309 Weselyn Drive-MCAdenville 28034 4-19-2023
Physical Address,City,and Zip SiJE f Certified W 1 ContNtor oUWell Owner Date
Gaston 221586
By signing this form, I hereby certify that the wells) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
" N -81°04' 41 .78" �, You may use the back of this page to provide additional well site details or well
35°15' 08.41
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.Formultiple injection ornon-watersupply wells
DAILY 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 ID#: WSW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: — 41 (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: 36" outer (in) above, also submit one copy of this forth within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: — 41 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
—36 6e.Outer casing length(if known): (ft.) lOc.For Water Supply&Iniection Wells: In addition to sending the forth 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
6L Inner casing/tubing length(if known):—(ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I

ecea
WELLID. NO. EXCEL CIVIL 8 ENVIRONMENTAL ASSOCIATES
WSW-1 QUALITY 0 RELIABILITY 0 INTEGRITY 0 SUSTAINABILITY
PROJECT: J.E. JENKINS
J09 WESLEYAN DR.
cADENVILLE, N.C. 28034
36" 36" 36" GRADE - 0'
CONCRETE CAP /SL/AB
36" SURROUNDING THE OUTER %
STONE CASING OF WELL. N%\\ Am-
3K Psi CONCRETE
STONE CASING
BENTONITE tz
PLUG ;
..........i.
33
5
UNDISTURBED EARTH
.A.
I-47A
'y
5T
%\7
--X
t
TOTAL DEPTH
41' BGL
HAND DUG STONE WELL
WELL CONSTRUCTION DETAIL
(TYPICAL - N.T.S.)
F:JOBS/FORMS/WELLCONSTDTL-4.19.23