Catawba_Well Abandonment_20230515 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Alfred Kiesling 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
3266—A wells abandoned:_
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): al
B & K Well Drilling Inc ` )
FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: Chlorine
2.Well Construction Permit#: D(0 o2402/ J3"Id.2 V
List all applicable well construction permits(i.e.UIC,County,State, variance,etc.)iifknown
7d.Amount of disinfectant used: �b d� C-e-�j
.F 4
3.Well use(check well use):
F103Agricultural
er Supply Well: 7e.Sealing materials used(check all.that apply): MAY a
❑Municipal/Public PTNeat Cement Grout b 2QZJothermal(Heating/Cooling Supply) ❑Bentottit C jps )rPellets
g PP Y) RResidential Water Supply(single) ❑Sand Cement Grout t�fn,^SFht,. UN❑Industrial/Commercial ❑Dry Clay is j s. 4
❑Residential Water Supply(shared) ❑Concrete Grout
❑Irrigation ❑Drill Cuttings
Non-Water Supply Well: ❑ Specialty Grout ❑Gravel
❑Monitoring ❑Bentonite Slurry ❑Other(explain under 7g)
❑Recovery
Injection Well:
7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heat i ag/Cooling Return), ❑Other(explain under 7g) /)'l l k CL1� �J J r
4.Date well(s)abandoned:
5a.Well location:
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
(Q HG ��lam,•.,
Physical Address,City,and Zip Signatur of Certified ell Contractor or Well O er Date
County By signing this form:, I hereby certi' that the we110) was(were) abandoned in
Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.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 W You may use the back of this page to provide additional well site details or well
CONSTRUCTION DETAILS OF WELLS BEING ABANDONED abandonment details. You may also attach additional pages if necessary.
Attach well construe ,records)iilavailable.Forniultiple injection ornon-watersupply wells SUBMITTAL INSTRUCTIONS
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
66.Total well depth:
Division of Water Resources,Information Processing Unit,
(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: (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: �� (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
6e.Outer casing length(if known): (ft) loc.For Water Supply&Iniection Wells: In addition to sending the form to the
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
6E 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