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Home My WebLink AboutCatawba_Well Abandonment_20231006 WELL ABANDONMENT RECORD For Internal Use ONLY: j i 1.Well Contractor Information: WELL ABANDONMENT DETAILS A. 15 � ftmai 7a.For Geoprobe/DPT or Closed-Lo lip Geothermal Wells having the same Well Contractor Name(or ell owner personally abandAing well on his/her property) well construction/depth,only 1 GW-30lis needed. Indicate TOTAL NUMBER of wells abandoned: NC Well Contractor CertificationNumber, , 7b.Approximate volume of water remaining in well(s):�" 0 (gal.) 1 Ar' M u 1 4 ?U!w tt C. FOR WATER SUPPLY WELLS ONLY: Company Na4 � /� �t'.� �'^�� n 7c.Type of disinfectant used: UI 4' 2.Well Construction Permit#: @v�1 =Q1 U f� pf List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflanorwt l O7_ 7d.Amount of disinfectant used: 3.Well use(check well use). Water Supply Well: 7e.Sealing materials used(check all that appl ): ❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ( entonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) E/esidential Water Supply(single) ❑ Sand Cement Grout' ! i 5 p"ET'Dry-�Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) El Concrete Grout 12,14nll Cuttings ❑hri ation ❑ Specialty Grout O C T O U 2023 Gravel Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g) ❑Monitoring ❑Recovery Injection Well: 7f.For each material sele&a'Aiiy�,lpt ovi e amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation I^(h 1�C 1 d I ■„0 l�Q�� ❑Aquifer Storage and Recovery ❑Salinity Barrier YJJVV�� a YJ�-��ot4 lK lJ� ❑Aquifer Test ❑Stormwater Drainage ❑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) J Y� CAT ` X 4.Date well(s)abandoned: Sa.Well location: Facility/Owner Name Facility ID#(if applicable) 8.Certification: Physical Address,City,and Zip Signature of Certified Well CorrIKctor or Well Owner Date l "WJCA_ By signing this form,I hereby certify that the well(s) was (were) abandoned in County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner. Sb.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: 3 S 5(� 2 I n N �' h �' n� W You may use the back of this page to provide additional well site details or well V/ �J y/ V Vl 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.Fornwltiple injection orno n-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#: abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Injection Wells: In addition to sending the form to the address in 10a 6e.Borehole diameter 15 (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: ` (ft.) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the address(es)above,also submit one bopy of this form within 30 days of completion n I of well abandonment to the county health department of the county where 6f.Inner casing/tubing length(if known): 1 4� 1 ft.) abandoned. i i 6g.Screen length(if known): �` (ft.) Form GW-30 North Carolina Department ofEnviromnental Quality-Division of Water Resources Revised 2-22-2016 WELL tB ONTAMN T CORD I F-IntemalUseONLY: I:Well Contractor Information: WML-ABt1.N4DONMENT.IDET'AIY,S d Tm-ForGeoprobe/IDPT or Closed-Loop Geothermal Wells having the mute Well Contmetor e(orweltmvnerpersomllyabandoniazy ilonbis&crpropcity). well construction/depth,only IGW30fin . indicate TOTALNUM$ER.of welts abandoned.-_ �C , i NC Well Contractor Certification(r I Numlrer '30 C�7b.Approximate volume of grater remaining in well(s): (gaL} k 1� ll`c t lrt�V1C4 ^��LI l�E f116 FOR WATM SUPPLY WIMLS ONLY: ' 3`'o CR C—PMYNAM7c.Type ofdisinfectaat and• 2.Well Construction Permit LUI,W appltcaNeuVll ra WC;Cwa*i Sia"Ymdmu�etcJ J iro 7d.Amnimt of rTistaWant used C.0 3.Wall use(sheds well use): Water.Sapphj WrD: 7e S csdl�gmatesluig used(cltec2s.4ituYtaPP�'Y)� QAgricultutai QMunicipaMblie Q Neat Cement tn➢t,'r -j g i. 'Q Bentonite Chips or Pellets QCazothetmal(IiestiaPfCoottiSuPP deutiat Water sm -.,z- pPjY( g�) ❑Send Ccmtmt 6rtittt*�.F—d. y F','y Dlndustrial/Com ndcial ulential W ter Supply(shared) Concrete Grout 0 r 7 I Q Dr 11 Cuttings Qlrri. . Q specialty Grout ` I 0 G 2023ct(gavel Non-WaterSupplytVeII: ❑Bentonite ',, ❑Other(explain under 7g) QMonitormg: 011ecovery �r GiS�?�xsJ Injtrtien1.: : 7£: or esiebalfs8ha�b ate.�itovlde;rtmotliit�dlaaa4erlals=nse7: QAquiferRecharge I7GroandwaterRemediatiori MquifaStorageand Recovery QSdb&yBmT!c /� �Aquifer?est ❑StormwaterDminage \A V1r,/�1Y_ ITY'�lt L Expegtttt atal'3e taulogy MubsidencaCai&d 7g.>frevade a brief destsiptaoa o4 clue abanrlonmeat procedure: OGcotbermal(Closed Loop) QTfacer `�-� QGeothermal eaten Coo A . 130d=.(e#jaittuader.Tg & t3.�l�- .a\ av+0t --- �i - -� :. '. 4.Date well(s)abandoned: Sa.Well location: _ SC�WI� Fact7ity/OtiverName Facility 00(ifapplicable) S.Certification: PhysxolAdtttess Cr(y aadZip 7? 5�1 Sigaanxcof W.HCo>rita rmWellOwner IDate 7S Bt>signi thls form.I hereby certi&'dtat the itwfts)ems(mere)abandoned in CaudY 1?arcelltteatificalionNo.go a--ar mina ulth Lfd_NW-02C_0I10D,or X.0200.T4H CwPx(mctfau,8rmidar.* and tiW a copy of this record Gas bent provided to the weff m%wer. Sb.Lafitude and longitrtde in degrees/arinntes/seconds or detdmal degrees: (if well fidcL one laUlong is sufficient) f J 9.Site diagram or addttiandim detntls 5 O 331 36 t)q f ' N �j 0 O!t /oa 3 6 W Port may ntie iti'e bade of lhis'page ud{p{ovide additional well site details or well • to abandonment details. You may also attach additional pages if necessary. lasr�utTeroly� �a s OF lE fs�s>;Irate AD l s s[�AL lie sTltlrCrrnivs dttarhuelteoustrucRonrncdrd(s)tfmntlkble Fernti]trjileirjeuioiiorn6ir-ttrrtesfrpplyirefl �. ONMvIth go same constrnctfonlabaadmm,ert,you can submit onefo m. ►� } �y -y��/ 10a,—Em-A LW-,d s Submit,thisv.farm.wnhin:.30,days of cowpietioa:of .wul1; La.Well HW. i / /bZ-� abandonment to the following: • �,' Divistan.uf V1'�te�•BcHearees,tofiirmatitiu:P.:ncsssing:llnit,- 6b.Total well depth: 00 1617 Mail Service Center,Raiclgh,NC 27699=I617 3� 10b.For Isiecton We`„m in additi.t to sending the foraa to theaddicss in 10a 6c.Borehole diameter- ® fin) iibove,also suliniai one.copy of this form within 30 days of completion of well abandomnen(io the following: 6d.Water level below ground surface: (ft) Division of Rater 1Sesourees,ilndergrotmd Iajeetioa Control Progrxnt, 1636 Mail Service Center,Raleigh,NC 276994636 6e.Outer rasing length(irlmown): 5 (gt) 10c.For Water Supub,&Iniectlon We In addition to sending the form to the addressics)above,also submit one copy of this form within 30 days of completion of..weW-abandonment to the couuty.health department of the county where 6f.Inaer casing/tubing length(dlmown):_ _(ft) abandoned. 69 Scrcealength(ri'Imo ).hj/h (M) 1 FarmGVV..i0 Y-Rlh tmlittaDepwtmntOfFsvimrMertel t 2_C!'.!^tity-]li<isinss Qf�l xter Re�.oe3 I Resist_22-1Atb