Caldwell_Well Abandonment_20230912

WELL ABANDONMENT RECORD For Internal Use ONLY: '
1.Well Contractor Information: WELL ABANDONMENT DETAILS
"B?AbLes 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 its needed. Indicate TOTAL NUMBER of
wells abandoned: 0o C
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 3� (gal.)
FOR WATER SUPPLY WELLS ONLY:
Company Name
. 7c.Type of disinfectant used: Cl-DQAX PyDL
2.Well Construction Permit#: Xbldk- �NOt t�>J �Soow1 OrcaiweO-S rRst'<�
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflatown
7d.Amount of disinfectant used: Z. i b5
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ' ❑Bentonite Cb-)s or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout I ❑ Gravel
Non-Water Supply Well: _
❑ Bentonite Slurry Other(explain under 7 )
❑Monitoring ❑Recovery v lL�l-�- FtLL (1CS 5
Injection Well: r r.,.�io �each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater edia }
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drain.H P 1 2 20.3
❑Experimental Technology ❑Subsidence Control
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7 T 2►JEr1 77r.:V-*W' .II' dkide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑TracerJeo
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) WEL1- Q[P,t4V r YL)l A?- ?-�by wE4'+wAT 8
3) taAweA e!of eAs 1 d 6 `{ -yowpei M z4"i lwoo (3�5I cy(a
4.Date well(s)abandoned: 0 z3
5� WJD J 1)151t4F0CTt=Or- to� C-tLLJM WELL- Rt0' Q AkWUM
Sa.Well location:
• .,(�(�L3 M1et1�rL�--C3R:�.� t��t w t� CoNc�-6'CG; U�CU- ft1-�.�4Ptet}� gt
N R- ��S t o► OTG -7 P.VTr,� eol�CPj&-Clr sESr d P .Solt.
Facility/Owner Name Facility ID#(if applicable) 8.Certification: a pt gip_ u� p lh„tq Lit EU2W-
6dD20 f.00I�-`i MUV RA (� t(tTL LL S ►��- . h4 ✓l c./ JS�- 5 Wz3
Physical Address,City,and Zip 66nature of Ceilified Well qontractor or We I t Owner Date
C�t��LZlr 3-705 Ll4 22-G to By signing this form, 1 hereby certify that the well(s) was rwere) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C 10100 or 2C.0200 Well C-istruction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: !
(if well field,one ladlong 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 record(s)ifavailable.Formultiple injection ornon-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells:" Submit this form within 30 days of completion of well
6a.Well ID#: 0001 C>-' 1-� abandonment to the following:
fDivision of Water Resources,Information Processing Unit,
6b.Total well depth: 44 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2-� (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 Z01 (ft.) Division of Water Resources,;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): y14 KtJo"3tJ (ft.) 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
of well abandonment to the cotutty;health department of the county where
6L Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): UrJr--t-�N (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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Caldwell County Health Department 2345 Morganton Blvd. Lenoir NC 28645 =_
Well Construction Pe Page ! off P:(828)426 7,9i Fax:[phone]
El New We ❑ RepairAbandonment NC PIN#37 12%11& WP#
Issued to: I&Wes Twjk42 ISubdivision: AILA I Lot No. Section:—
Address of the property K n ; 2 6 . Lot size:
Directions to site: 32-( So.,4µ., . �?AjeGHE,t2 ST L finis ,P *,A—e wjry
Facility well is to serve: jt Septic•IP#:Z y3 2678o
Properties this well is to serve: p p rr.IT. Date septic installed: '
This permit is valid for a period of five years except that it may be revoked at any time if it Is determined that there has been a material change in any fact
or circumstance upon which the permit is issued.Final well head construction must be Insoected and approved by CCHD before a certificate Of
oct n"m is granted or the well is placed into service. The location of the well indicated by CCHD is to provide protection from possible:.wrces of
contamination. Flow volume(well Yield)is NOT guaranteed at anv site by CCHD.
fNCGS
icant J Legal Representative Signature:
s7-ss a-wee `( Date: / /
Pumps can only be Installed by:
ll Drillers,2)Homeowners,3)ONLY plumbers with documentation of continuing education covering well installation with in the last two years
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$4 4 �
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Not TO Scale
❑ Separate as-built attached
The well driver must call CCHD.between 8-9am to schedule. rout inspections. Drillers must verify all required separations before dulling
the well. If the well driller' able tom ' tain re uired separations,contact CCHD at(828)-426-8579Ibefore drilling the well.
1)Permit REHS#_ I Date
2)Gro petted' REHS#
OR ❑ Contractor certification for grouting not witnessed by CCHD (ZC.0305) I Date
tWedl
ut Depth: (ft.) Type: Method: Driller Company:
Casing Diameter. in De th ft I ua.Driller.•
ficate of Completion: I rt#
REHS# Date
l Head Casin Ht.: (in) ❑ Port/Vent ❑ Well.Seal ❑ Threadless Sam `le Tap ❑ GW-1a or GW-30
Plate .0107J(2) ❑ Date: Depth (ft.) Yield m)Static H2O ; (ft)p e ❑ e' ur _ er i
Lertw
4)Water samples Collected:
REVS# I ', pie
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