Gaston_Well Abandonment_20230915 (7)

WELL ABANDONMENT RECORD For Intent I Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William J. Miller 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 is needed. Indicate TOTAL NUMBER of
2927A wells abandoned: I
NC Well Contractor Certification Number � r 7b.Approximate volume of water remaining in well(s): (gal.)
Catlin Engineers & Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name b
2023 7c.Type of disinfectant used:
2.Well Construction Permit#: Iroorma sml ipfe'N: yZ ljl':
List all applicable srell construction permits(i.e.UIC,County,State,WiNgSW 7Lj�fkno+rn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry C Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑Groundwater Remediation Bentonite 50 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete 12.5lbs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Hydrated bentonite to 4 inches below land surface.
Concrete used to bring opening to grade. All well
4.Date well(s)abandoned: 8/3/23 materials left in place.
5a.Well location:
Ralph G Sellers Jr 00-030142
Facility/Owner Name Facility ID#(if applicable) 8.Certification: /
7152 Dallas Cherryville Hwy, Cherryville, NC 28021 8/4/2023
Physical Address,City,and Zip Signature of Ccrtifrcd Well Contractor or Well Owner Date
Gaston County 3509492178
By signing this form, 1 hereby cerlify that the well(s) was (here) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat(long is sufficient) 9.Site diagram or additional well details:
35.373787 N -81.333959 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 consiniction record(s)ifm•ailable. Formulliple injection ornon-sraterstipplyu•ell.v
ONLY with the saute constrtiction/abandonmenl,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-9 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob. For Iniection Wells: In addition:to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (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: 18.86 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) 10c.For Water Supply&Iniection�i
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 county health department of the county where
6f.Inner casing/tubing length(if known): 15 (ft) abandoned.
Id ,
1
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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