Gaston_Well Abandonment_20230915 (10)

WELL ABANDONMENT RECORD For Intern 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:
NC Well Contractor Certification Number � ' � •Approximate volume of water remaining in well(s): (gal.)
Catlin Engineers & Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 4
Uzi 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable rrell construction permits(i.e.UIC,County,State,ft-tdnpl-, t1jknou`,n
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
❑hrdustrial/Commercial El Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry e Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 37.5 Ibs
❑Aquifer Storage and Recovery ❑Salinity Bdrrier
❑Aquifer Test ❑StormwaterDrainage 5011 50Ibs
❑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.
Soil used to bring opening to grade. Concrete
4.Date well(s)abandoned: 8/2/23 pad and metal removed along with 4 inches of PVC.
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 Certified Well Contractor or Well Owner Date
Gaston County 3509492178
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 2C.0200 Well Constriction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the ivell owner.
(ifwcll 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 tirell construction record(s)ifavailable. For multiple injection ornon-watersupply irells
ONLY with the same construction abandonment,you tail submit one forut.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#' MW-13 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
10b.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:
15.47 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) i
1636 Mail Service Center,Raleigh,NC 27699-1636
tie.Outer casing length(if known):
NA loc.For Water Suoaly&Injection!Wells: In addition to sending the form to the
(ft.)
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.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016