Gaston_Well Abandonment_20230915 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAIL S
William J. Miller 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandpmnglvell mrh[Sd"bi tafo well construction/depth,only I GW-3i0 is needed. Indicate TOTAL NUMBER of
;^` ��d ED wells abandoned:
2927A 4 °a L-
2023 7b.Approximate volume of water rbmaining in well(s): (gal.)
NC Well Contractor Certification Number S E P 1
Catlin Engineers & Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
W-1;V V 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction peratits(i.e.UIC,County,Slate,Variance,etc.)ijknowtr
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout G 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 G Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 25 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage SOLI 25lbs
❑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.Datewell(s)abandoned: 8/2/23 pad and all metal removed. PVC was 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 Certified Well Contractor or Well Owner Date
Gaston County 3509492178
By signing this form, I hereby certifylthat the wells) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0/00 or 2C.0200 Well Consir action 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:
(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
Attachwe!/constnrctionrecord(s)ifm,ailable. For nradliple injection ornon-srntersupplywells
ONLY with the same cansnvction'abandonntent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-24 abandonment to the following:
Division of Water Resources,Information Processing Unit,
20 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth:
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 f jrm within 30 days of completion of well
abandonment to the following:
I
6d.Water level below ground surface: 11.05 (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 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): 10 (ft.) abandoned.
�I
6g.Screen length(if known): 10
Form GW-30 North Carolina Department of Environmental Quality-Division of Watcr Resources I Revised 2-22-2016

-s
MW-17 ®MW-15
. I
MW-16 MW-8 MW-14
MW-19
CURRENT,
'MW-1 MW-1'1 8 MW-22
T '�®t
BAS
MW-6 I ® ® MW-20
41
t# w ® MW-5
MW-9
MW-13 MW-23
�.�f` MW-21
APPROXIMATE
' ,�► MW-1 DMW-1 MW-10 ® LOCATION
® MW-1A OF DRUMS MW-24
1� MW-7 ® (9 MW-4
MW-2® A ® MW-12
FORMER
UST-BASIN
LEGEND Oq
< x�
® Abandoned Monitoring
Well (Type II)
OAbandoned Monitoring
Well (Deep)
Approximate Location }'
of UST Systems
Parcel Boundary ` ;
Source Esri, PAaxar, EaRhsta Geog•aphics,and t G15 Use Co nIII
NOTE: Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 60 30 0 60 120
Feet
PROJECT TITLE
RALPH SELLER'S SERVICE FIGURE
ATLIN 7152 VILLAS- SITE MAP
CHERRYVILLE HWY
CHERRYVILLE, NC
Engineers and Scientists
INCIDENT N0. JOB NO. DATE SCALE DRAWN BYICHECKED BY
14350 221173 SEP 2023 AS SHOWN KMC/SJO