Gaston_Well Abandonment_20230706 (2)

WELL ABANDONMENT ONMENT RECORD For Internal Use ONLY;
1.Well Contractor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
ER of
Well Contractor ame(or we l owner personally abandoning well on his/her property)r well construction/depth,only 1 GWI 30 is needed. Indicate TOTAL NUMB
wells abandoned;
NC Well Con o�Certiification Numb 7b.Approximate volume of water remaining In well(s):
7 — �� �, �' FOR WATER SUPPLY WELLS ONLY:
'Company Name 7c.Type of disinfectant used: 7
17
2,Well Construction Permit#: �
List all applicable well constritetion permits(i.e.UIC, - o State,-ardancetietc).j nown �
=_• u y a 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: JUL 0 6 2023 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mun ipal/Public ❑ Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) idi1U )tatec S`u pfy'�sr�nglf�)L ❑ S d Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residentialti� ,',�gter-Sttppply(shared) Concrete Grout ❑Drill Cuttings
❑Irrigation R p •C'rr{' .¢�/G'�i ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
injection Well: 7f.For each m terial selp4ted abo a provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
.❑Aquifer Storage and Recovery ❑Salinity Barrier / r
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,pro de a brief description of the abandonment procedure:
❑Geothermal(Closed Ltiog) ❑Tracer �
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date wells)abandoned:
so. 611location:
�Ptv
8.Cc cation:
Facilvtoviner Name i Facility ID#(if applicable) F
?hysioal Address,City,and Z' , Signature ofCerdfied Well Contractor or Well Owner Date
• R 9 _ By signing this form, I hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 at-2C.0200 Well Construction Standards
and that a copy of this-record has been provided to the well owner.
Sit:Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lorig is-sufficient) 9..Site diagram or additional well details:
,- GI A N /" 6)- ^ I W You may use the back of this page to provide additional well site details or well
:J abandonment details. You may also attach additional pages if necessary.
COiNSTRUCTION IDETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
,..Ittach well constructionirecord(s)ifavailable.For multiple injection or•non-water supply wellr
ONLY with the same eopstnrction/abandonment,you can submit oneforin. 10a. For All Wells: Submit this fort within 30 days of completion of well
abandonment to the following:
6m Well ID#:
Division of Water Resources,Information Processing Unit,
6b:_:Fotal well depth:.
4� (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
"
10b.For Iniection Wells: In addition to sending the form to the address in 10a
0c:Borehole diameter: (in.) above, also submit-one copy of this form within 30 days of completion of well
abandonment to the following:' .
Division of Water Resources,Underground Injection Control Program,
Gal.Water level below ground surface: (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Suuuly&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): _(ft.) 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
(I abandoned.
6f.Inner casing/tubing length(if known). (ft.)
A
6g.Screen length.(if known): ® (ft.)
' Revised 2-22-2016
Fur7rr GW-30 North Carolina Department of Environmental Quality-Division of Water Resources