Catawba_Well Abandonment_20230724

WELL ABANDONMENT RECORD rorlatemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
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7a.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same
Well Contractor Nah Orwell owner personally abandoning wall on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
tag!A
A wells abandoned:
NC 6Vell Contraacctor Cedi&setion Nrm tw 7b.Approximate volume of water remaining In well(s): L (gal)
FOR WATER SUPPLY WELLS ONLY:1-
Company 7c Type of disinfectant used:
2.Well Construction Permit#: '- ) 1 Z7Z
List all applicable well constriction pemitts a.UIC,Cotmry,S7ma rb lance,eta)/flormnt , CN 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Welh 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipabPublic ❑Neat Cement Croat 17d Bentonite Chips or Pell&s
❑Geothermal ftating/Cooling Supply) ` Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑lndustrial/Commemial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cutting' f `r% r_
❑Irrigation ❑Specialty Grout ❑Gravel � �"=G E;V
Non-Water Supply Well: ❑BentoniteSl "-�i�
❑monitoring ❑Recovery °� ❑00ter(explain uge�er 7g)
�l,J� ,,1 2023
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroandwatuRemediation `� in+�.r ir''��f^;may®-� �tGa
h '. � ,G5
❑Aquifer Storage and Recovery ❑SalinityBarrier C�
❑Aquifer Test ❑Stormwater Drainage Jl'
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tmeer r d `�
❑Geothermal(IIeating/Cooling Return) ❑Other(explain mad<—.7g) e i `� V
4.Date well(s)abandoned:_r u L �- c �, A\k b�r p '1
5a.Well location: ` �
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Facility/Ownir Neme Facility IDN(ifopplicable) IL Ce�rtificatio!
P li Address,City,and Zip Signature of 1IC Well Coar net 0r or Wel�Owaer Date
"'-,wNt--., cL,,,A-,N 3-tL30��� � By signing this form,I hereby cenifi,that the well(s)Nns(were)abandoned in
County Parcel Identification No.(PIN) accorlance with 15A NCAC 02C.0100 or 1C.0100 Well Construction Srandm ds
and Brat a copy of rids record has been provided to the irel/ouster.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifyyivoll fieki,one latilong iss�s Ir ma) ® d j 1 9.Site diagram or additional%veil details:
I✓3 5 ��5�( 7 9 N N G J 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 irnecessary.
CONSTRUCTION DETAILS OF WELLBI BEING ABANDONED SUBI%HTTAL INSTRUCTIONS
Atrochnvilrnnstructfonrecord(s)tfmvrlable.Formul6ple injection ornon-kntermff4,avlls
ONLYwItk the some constfuctionlabandonment you can submit one form
, 10a.For All Wells: Submit this farm within 30 days of completion of%yell
6a.Well ID#: tt1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth: (it-) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6a 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: t (ft) Division of Water Resources,Underground Injection Control Program,
16361%fall Service Center,RaleW NC 27699-1636
Ge.Outer casing length(if Imo%vo): ft (ft,) loc.For Water Sunnly&Injection Wells: In addition to sending the form to the
address(es)above,also submit one ropy of this form within 30 days of completion
of well abandonment to the county health department of the county where
GC Inner casing/tubing length(if known): (IL) abandoned_
Gg.Screen length(dkvo%vn):
Form GW 30 Nash Carolina Department of Environmental Quality-Division of WaterResomms Revised 2-22 2016