Gaston_Well Abandonment_20230818

WELL ABANDONMENT RECORD For Internal Use ONLY:
L Well Contrac for lion: WELL ABANDONMENT DETAILS
Af(— 79.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally aband ' g well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
0 wells abandoned:
NC Well Contractor C 4['on Number 7b.Approximate volume of water remaining in well(s):—(gal.)
FOR WATER SUPPLY WELLS ONLY: ]
Company Name 7 7
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)tfhnown
7d.Amount of disinfectant used:
3.Well use(check well use)::
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑M ' ' blic ❑Neat Cement Grout ❑ Ben�tonitte Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Zlesidential Water Supply(single) ❑ Sand Grout e'Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) on©-C Crete Grout ❑ Drill Cuttings
OIrrigation ❑ Specialty Grout - ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7£For each material selected above, rovide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation ` 4-4
❑Aquifer Storage and Recovery ❑Salinity Barrier — ' #e d j C1 '1 r�
[]Aquifer Test ❑Stormwater Drainage 0/)c roe la,.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop): ❑Tracer
7g.Provide a brief description of the abandonment procedure:
�
❑Geothermal(Heating/Coolin Return ❑Other(explain under 7 ) fir+ �/� 1 ,i
4.Date well(s)abandoned: 3 AUG 1 O
29231
5a.Well Ioc 'on:
nAN0130G
Facility/ eryNam Facility ID#(ifapplicable) 8.Certification:
Physical A City,and Zip '�-
Signature of Certified Well Contractor r Well Owner Date
f By signing this form, 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
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field one IaUlong 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifazaileblc.Formultiple injection or non-water supply wells
ONLY with the same consiruction/a and nment,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:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: A) 1617 Mail Service Center,Raleigh,NC 27699-1617
p or 10b.For Iniection Wells: In addition to sending the form to the address in I Oa
6c.Borehole diameter: t;-1 (in.) above,also submit one copy of�this form within 30 days of completion of well
/J abandonment to the following:
6d.Water level below ground surface / � (h) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): � � (ft,) lOc.For Water Suoaly&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
/+ /f of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 'e V,/� (ft) abandoned.
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6g.Screen length(if known): g ^-t (fL)
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Form GW-30 North Carolina Department of Environmental Quality-Division of W ater Resources Revised 2-22-2016