Gaston_Well Abandonment_20230915 (3)

WELL ABANDONMENT RECORD For Internal 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 I GW-30 is needed. Indicate TOTAL NUMBER of
2927A wells abandoned: i
NC WeII Contractor Certification Number RECE'
1 ^"'r 7b.Approximate volume of water remaining in well(s): (gal.)
Catlin Engineers & Scientists FOR WATER SUPPLY WELLS ONLY:
1 Company Name SEP 6 2023
7e.Type of disinfectant used:
2.Well Construction Permit#: (pAarvmi�i-fl i
List all applicable well construction permits(i.e.UIC,County,Sta101AJQr4t2t:)(V if town
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 19 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/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)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 37.5lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 5011 50IbS
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g) Hydrated bentonite to 4'inches below land surface.
Soil used to bring opening to grade. Concrete
a.Date well(s)abandoned- 8/2/23 pad and metal removed. Approximately 5 feet of
5a.Well location: PVC was removed.
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, 1 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
and that a copy of this retard has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(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 construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction'abandonnnenl,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• M W-21 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25 (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:
I
6d.Water level below ground surface: 13.92 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
6e.Outer casing length(if known):
NA (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 county health department of the county where
611 Inner casing/tubing length(if known): 5 (ft.) abandoned.
6g.Screen length(if known): 25
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources - Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAIIIS
William J. Miller f
7a.For Gcoprobe/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:
( 4L V•[� � �r
NC Well Contractor Certification Number �A�. X_%4 5_� 7b.Approximate volume of water remaining in well(s): (gal.)
Catlin Engineers & Scientists SEP 1 5 `7023 FOR WATER SUPPLY WELLS 01NLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable irell construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
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 i ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry N Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
q g
❑A uifer Recharge ❑Groundwater Remediation Bentonite 25lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 5011 50 IbS
❑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, all metal and approximately 10 feet of PVC
5a.Well location: removed. 1
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 cert�that the tvel!(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong 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 WELLS)BEiNG ABANDONED SUBMITTAL INSTRUCTIONS
Anac/t well consintctiott records)ifavailable. Fo-ttndtiple it jetxion ornon-iratersttpplyirells
ONLY with the sante construction abandonutent,you can submit one form.
10a. For All Wells: Submit this form within 30 days.of completion of well
6a.Well ID#• M W-22 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 23 (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:
13.03 ft.) Division of Water Resources,Underground Injection Control Program,
(
1636 Mail Service Center,Raleigh,NC 27699-1636
i
NA loc.For Water Supply&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (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): 8 (ft.) abandoned.
l i
6g.Screen length(if known): 15 (ft.) I 1
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016
I