Gaston_Well Abandonment_20230807

WELL ABANDONMENT RECORD For Internal Use ONLY:
1. ell Contractor Info ation: WELL ABANDONMENT DETAILS
l /l e 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Nime(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2 /) wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
L1.2 Jae
SE�)�� elc rr J�f/C FOR WATER SUPPLY WELLS ONLY.
Company Name 6 7c.Type of disinfectant used: (Da-go 6 lJ oq ear A
2.Well Construction Permit#:
List all appUcable well construction permits(ie.WC,County,State,Variance,etc)i f/mown 7d-Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
DAgricultural ❑MunicipaUPublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
[--]Geothermal(Heating/Cooling Supply) esidenfial Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
DIndustrial/Commerrial OResidential Water Supply(shared) Concrete Grant ❑Drill Cuttings t• r �.
Oh'ri ation ❑Specialty Grout ❑Gravel •� �. ';
Non-Water Su Well:
PP1Y ❑Bentonite Slurry ❑Other(explain under 7211,j
❑Monitoring ❑Recovery r/1,�
Injection Well: X For each material selected above,provide amount of materials used:')+;�_,�
DAquifer Recharge OGroundwater Remediation
DAquifer Storage and Recovery ❑Salinity Barrier
DAquifer Test ❑Stormwater Drainage �f4y
DExperimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
DGeothermal(Closed Loop) OTracer J I / ��O
DGeothermal(Heating/CoolingReturn) ❑Other(explain under 7 ) n�j(
a, I D COv.R
4.Date well(s)abandoned: Poured
b to c /ti eft i t d well
n
Sa Well location: J,)1 t t bfia' TC_. aAd C add i`t�, 'jJPI( �rr`Hl l to t�'n ,
Aid 1a valeADV 7
FaciHWOwner Name FacilityID#(if applicable) 8.Certification:
tP� Or.
v//'��l0/ ������v
Physical Address,,City, gnature o Well Con or or Well Owner Date �s
By signing this form,I hereby certify that the wells)was(were)abandoned in
County Parcel identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200.Well Construction Standards
56.Latitude and longitude in degrees/mfnutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/Iong 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
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifava(lable.For multiple infectlonor non-wafer supplywells
ONLY with the some construction/abandonment,you can submit one form.
10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well D)#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
61b.Total well depth: 00 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (ia) 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 27699-1636
6e.Outer casing length(if known): (h,) 10c.For Water Supply&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 �66,
of well abandonment to the county health department of the county where
GE Inner casing/tubing length(if known): (ft.) abandoned. ;
6g.Screen length(if known): 00
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I
I �