Gaston_Well Abandonment_20230706

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well pnt• ctor Informatji�on: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-loop Geothermal Wells having the same
Well Contractor Name(or well o erpersonally abandoning well on his/her property) well constraction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
.� A9 v j wells abandoned:
NC WWgctor Certificatiion/Number 7b.Approximate volume of water remaining in well(s): (gal.)
i(/�i // FOR WATER SUPPLY WELLS ONLY:
)
Company Name
7c.Type of disinfectant used: (,
2.Well Construction Permit#: ] ��
List all applicable melt construction permits(i.e.UIC,Co hty SYtne�Ya iqace,.etc.)if47wwu 6
�t V� = t '• i' 't 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: JUL 0 G • OL 3 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) istitiht'X✓, er SnpJ�ily'(sttt tejr ❑Cement Grout ❑ Dry Clay
❑
..t:r
❑Industiial/Commercial Residential Wa �
fer Supply(shared) oncrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation :7 r )I}! ,Y
❑Aquifer Storage and Recovery ❑Salinity Barrier /i /
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.P ovide a brief desc iption of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer , [Il I� �
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) T
4.Date well(s)abandoned: [1
5a.Well location:
Facjli
l / � nle e, I
' . tion:F ity ID# f plicable)7e AVI 6 'vim
P ' I Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
�. z 0 By signing this fain, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds ordecimal degrees: and that a copy of this record has been provided to the well owner.
(if ry I field,one Iatho rg' sufficient) :7
^h N ap W 9. u Siteusediagramor additional well details:
, l�" / vlJ"` /,l 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
Attache ellconst•uctionrecord(s)ifavailable. For nntltipleirjectionornon-matersupplyivells
ONLY with the same consn•u4ction/abardonment,you can submit one forni. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 1 Rpl-ed
j }�j ] abandonment to the following:
(�,t `/ Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: (in.) above, also subunit 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,
j� 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): / / (ft.) 10c.For Water Suonly&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 Ihealth department of the county where
6f.Inner casing/tubing length(if Imown)AW (ft.) abandoned.
6g.Screen length(if(mown): /V (ft.)
Fonn G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-20 tG