Gaston_Well Abandonment_20231006

NVELL ABANDONMENT RECORD rarinigrnaalUsvONLY:
„This foian can b6'used,for sipgle.or tnuhipfe.wells
I.Well rador I'nfot'nvAtiont ��� WELL ABAYbC1N1titEN 1 DFTAELS
Cnnt
Rich Lemire 7a,Number of n•ells being;ahaindtined:.l
Wall 6niradibrNonii(4 i-.eII&vv Pca lt%&6ii lRSti'r propply F6F aurloplr lgvi:roil or m�Ja-ritirtar sa+1pA- 'sells .ONLY with Al sons
M1asa7rrcfJ,xa�OIYIOJItJ!�RJt,)vary avr,uahJut�ui�jFiri!a,
2593A
NC1Vdl
76.Appro mate villume of svatj r6itabdMI;in Wdl(s}t
ConlragorG:Uifiaaf3oarNrrn�cr �
SAEaACCo FOR WATER$VPPLV WEGI.S ONLY:
Caravany N,nas 7c.Upe of di5infiviant 6kd:
2.Well Construction Permit#: ,
llgaflajplkvbfeieffluinkril. Cwraly Su V.rV.ri--e.byviiur4retc)tf&J,uaito 7d:llnloulitof:d151nfi'CtulituSirl:
3.Wdl u: (clr Ck.vell Use):
Water Supply Well: 7e Scaling fnatMlas used(clicel:all that apply):
pt3gtici�lttt>atl AMitpicip tllPtatilic M Nc at Ccmcti(GWist 6d Hcfaon.itc Chips or Pellets,
AUcothcrtuatl(ticatinr�Coolina Supply) DRcsidentyal Water Supply(rtigle) D 5antl CeaterU u r .. v � pry Clay
❑bulnstciaL+Comnteteial OResidentialWater Supply ishamd) ❑ creta:'Graau ❑Doll Cuttings
❑fiti •tion f7 SpegW.ty Gilaut O C T Q 6 20230 Grdtel
Noa Water.SupplyWell: b,tentonite5ltny Cl 0.(her(explain under 7g)
MMUnitoriiag` t]Recocen_'.
Injection WvIl• 7G For each inatedal scl&iivlQabt 4$4 oAde amount of materials used:
D:�ttjuifcr Recta tege ❑Wofidtiatdr Retuedi:adon
❑Aquifer Storage aixl Rem'i�ry DSali-ty I)atrlor
❑AiguifcKTest ❑StoetmwvtrrUt>sha:tge
Bentonite.:5001b •,1Wtr:ga1.
❑E.xpeiinientul TMutologv Mubsidence Cos Ardl 79 PrYn Idc u brief dcscriptinri of the-'abandanmeat pt liv dure.,
Micoiltemral(Closed Loop) Mracer ;
Backfilled-boring w/ hydrated bentonite chips
cicceolhennal(Head turlCoolinaRetum) • 130dwor(explain under Lit)
4.Date ft(sj.46andaned: 9/8/23
Sa.Well luca6ty,
Wix Filtration'
racild}/4avrsrNcurro rxilitvMmGfnpplimbldy R.Cerlillcalioit: .
r�
1301 E.-Airline Ave. Gastonia, NC 28054 � .(1/jvti4wt:�' 9/25/2023
Physical Addtcss;Ci1';a p
ridZi skp.wiin 00-4:,illedW0.1Coiaia:WrurWct[th�rcr Dim
Gaston liv saga 1?kq Clads bv?4 I hemhy certifjv.dwr 1he wellts)was tic-are)abtuuituaed pi
('acinty III=clld>Uill,41lniaN&(PINj ciuuriUnt-etvfllr 1j.4.1�CACOZC';0100ur2C.02091ilvd-'aiS7ixtctfufi.Storrrltmis•
and Mat a cap),ofilds remrd lrusbeeitprovidsrlt -lire well 611ner.
SIr I.itioide and longitude In.degmstminutcstseconds ordechual dcgtv6:
or.,.•ell r'n.td,014! -9.Slto diagram or additfonatuell detalls:
You.nlay use;the back of this page to proyide.additfonal weft.site derails of well
N .. W aGaudotuurtd&iaila You ivay a6i attachh amitioUal paggs it taeeessaattt
CO NSTRTICMf1XDtTAILS OF WCLLlSI BllAM A13AND.0NED ulgil TTAL TNSTRIiCTIONS
attude ucll nurrtrndima niwdfs)'il."iU vv- l cir nmlLplr iilrctirin w run-uumr�arFplp
<a e1Ls ONLY mJtli 17x snJnr irJv can rrLirtil r,Jre fume , 10A: For All Wctls:, SOW( Il><s formtifthim 30 day:F of completion of t%+ell
Ga.Well IN nbandonmcat to the following:
Division of Water it.0iources,Infurmation-Prvicessing:IJUTA
Gb.Total ttrll depth: 40• (fd.)
1617 Mail Scnicc Ccdter RaId h XC 27699-1617
30b.Ek Inleclloa Wellm Ili addition to a.axjing thefornt to the address in IN
Gc 13amholedL�metcr:l (iu.} sabove-also•subratit.one copy of this form vtid"30 days of completion of.tt well
ubaadournetil la Elie follolSina
Divisloti of Water Resources;timdeigriattnd Lijectfuu CoM6I Prdiratu,
6r1,Water 1 c1.bc[nip ground nirtaec: {fG) 1636 51A SeniecaCcnier,Raleigh,KC 2 7 69 9-1 63 6
Gr.(Inter easing length lannwn): 30 (ft.) 10e..rnr Water Saannlc Sc.In[crtion Wells: In addition la sending the fomt to
Hie_:address(es) aboie, also sulifiiit.one copy of•this four within 30 days of
completion of►tell ahandnrun:ni to the coamty heafth depaatuatent of Mile connty
t hva abgmdoucd,
Gf.Inn�•casinftnl►fngl lcirgKlr(if ltiro��•n): (ft.) �
fin.Screen Ic'mith(if ltnon ti)s10 (ft.)
Form G1V-:ai1 Nonh Caroliw Deponnuav of Environancnt alai Natural Rcso<a.�cs—Division of Winter ct oures Raviscd,lugu0 Z013

i
WELL ABANDONIVIEN•T RECORD Fai[menial Us�ONLY: 1
This foim jai be usedffor singfe.or midiiple wells 1
1.Well Contractor lnfortnution: W ELL ABANbONh1ENT DETA`M4
Rich Lemire 7a,Number of wells being;abantluneil: 1
5Vc11'Cautcaiagrh'�mc)4rn lloSvc Pcran�lly:alramgangnortcglan}gsrltcrprupesfy) F'w nnrinpp trllecitair or ra,++=uatrr 81giph- ualii ONLY with the swne
c!NasfrrrcfJwJ�rbarcltnirrnwJt,pito ajF rJn•
2593A �.
NC 1Vcq ConlydgorG nirictliorl Nnn#tei '7b.Alipro-dmate'Ohaine of it ifil tettt:tining in isell(s)i WL)
sAEaAcco FOR WATER.SUPPLY WELLS ONLY:
Gouapan+Namc. 7c.Type of disinfectant used:
2.Well Construction Permit#:. ,
1lstirll.njiplJct+kle.iletl yerirritri(:u Cwrut4 St�v.lurlrus.l;JYciinl;,rrer luwt+•
7d,Amounfol'Alsinfi��t:tut tts+�l:'.
3.1ti'dl usr'(chet�:ri•cll u;iry: '
Water supply Well: 'ic:Seafing materials used(clircl.'all that apply):
AAgru:�tlfttrtl. l7Atiinictp,•tUPtttilic. Cl_Ngt Ccntctid.Gt�nt l-:. --- � ��AcWgtti�c C'higts nr Pellets.
(H gJ no Supply) pply(sin le r3 Sahel Cement Grout 't' r 1
l7Geothcurt I catin Cooli RSt l E]RcsidtntutI Witer S'li g; ) "'
❑hidustrial/Comnicrcial []Residential Water$Iuppl}•(shared) b Oncrcti'Grout O C T Q (j ��.jj ll Citltings
❑Irri tion 0.Specially Grout `f7-mai�el
Nop=Watcr.SupplyWell: — 13 Hentonite 5luny intwirw' 1�,t r rt,l_y iainut►der 7g)
®trla>tltodng" ❑Recotery.
Injcctign Well: X For each material selected above,provide amount of materials used:
❑Aquifer Recharge C]Gtat 11*110 Renteillatiari
❑Aquifer Sian)gc atki Rec?ai'tay OSuliuily Danicc
❑Ail uifcirTest ❑Stoimiit�terpttiitloge" 8entonite.:5001b ,Wtr:gai.
❑E.�eiinieulttl T�:httaloly ❑S�sldeiice Cuttttvl 7g;Prui•idc a 1►ricf description of the vbaicttnnment ptt►eivlurei
rMcolhermal(Closed loop) OTracer.
Backfilled boring w/ hydrated bentonite chips
Maothentitl(lit"ttittKoolinxRetum) ®Other(e.2lain under Ljo..
4.Date.well(sl.aWndoncd: 9/8/23
$a,Nell location:
Wix Filtration
Faci1ityi0witcrNa,n6 Faciltty IVM(fapptimblsd li•.Certi[Icalloit:
1301 E. Airline Ave._ Gastonia, NC 28054 `h _ M'w_ 9/25/2023
Physical Addres;City,-and Zip 5igmilly aPt_.=:111W Wt ll:�m'r,%wi nr Wc1l do n:r Vine
Gaston 3r sr3lair>tq this farm, !hemby ceJ•ti,jy,dwt the uellfs) was prore)ah+mdoned in
Gauuty I'.tmclldealit�atlnitNo.(PItSj rJccuttfatace tvillr l,:i:1'C'1IC 02C talt?a Ur rC_U2r?D.i6irll COJia'lr+tcllora.Sfi+gtk+rcls
and dral"a cwpy ofliris record/HIS beeir Providedf&&6l cl!dw)ier.-
Sh.;Latitudc atid.Itingituitc in.dcgr ces7is inutc sFssennds,ur dtxim ll degrees,
(Itli'cll told,one ialhajtd u stac5.go) '9.Site diagram or additional well details: ,
You.nia}•arse ilk bii&of.this page to pro}•i&addilional icelf.site.deiailvoi tcell
h• �V a!a'nndotuneiti d'etaila YOUiuug also acich additiotia['pas if nececsitty_"
CON5TRUCTION.1l1 TaII..S OB WELL(4)14191RC ABANDONED St1RpTT TAL INSTRUCTIONS
.trtadt i ell currslra didu nn wrd(ts)O'c;iWdMr_ Frig nrnhiplr iilrctirite ur'lian•lra+ar slrpJah '
w4h ONLY if-Jill 1h.0 farefinte. 104t:"For All Wells- Submit tlii3 ffami within 30 days of completion-of well
6a Well ID •GTA-9 abandonrdcitt to ttrc rollowin�:
Division of Water Ree'ourem,Information Prueessing;Unit.
fb•To[altveU depth: 24 (ft.) 1G191lLiifScnicc1Crnrer,.iialei(;h,11C 2 7619=1 6 1 7
10h.I&r Iniecti n Wells: In addition to setaling ills form to the addi-ess in 162
l abwve.also subudt one copy.of ibis form aithiit"30 days of completion of well,
Gc.Borehole diameter (iu:) :Ibundountem In the fallolvins: ,
Divisloti.tiY WaterRessoitrci ;ilnder eiiutid hijectlou Conitvl)'rtig ram,
Gd.Waterlot'cl hcioi)grotind•urfacee (ft7 1636 Mail.Scnicc(enter,Raleigh,NC27G99-1G3G
6c.Outer casing tength(if tine n): 14 (ft.) 14c.,Fnr Water 5'aniv&llttiic I iffin Wen': In addition tv sending the font to
the addresses) aboye. also suiiinh.one capy of this tbmt NAthin 30 days of
completion of well abandomncn�.to the county It£ahh-deparinic tt of Ute county
Gr.lnnireasing(tubing leiigth of tmuwn): {iy) tvheri aharidoncd.
I ;
I
Gg.Screwn length(if knob n):10
Fum G1Y.t Noah Caolln Dcpomnt ofniltnoocot and Natural Rcsouzcs_Dlsison or water cswcts Revised Aqua 3U_t..
I.

l
NVELL ABANDONMENT RECORD For ttocMdl)seONGY:
.,Tbis feint can be used.for single or niuhijik vv'M
1..Well Coutractur Information: WFLL ARAM]IONXIENT DETAILS'
Rich Lemire 7:t,Nirntber of reps briny;aband!ned:.l
lti@]C+CtoracacfbrNonit(qr.4r(L�tt jk�azislly.almmlaninaaell.an liis lter'prape>9ya fcir 6afinple. Mirelfar ou' rum-i•otcr suppb- welds ONLY wide N,e smite
. c+nn?trrrcawi'tvattciclirn+ryrt,)nr+itvr.ta�dvldt arafarm,
2593A )
71r,Approve'.Late-volume of tvater rteinaming in Ivell(s): {fiat.
NC IVd1 CanlragorCettiftcaBou�Nunabcr i,
sAEaACco FOR WATER SUPPLY WELLS ONLY:
Caaayany Name Tr.Type of disinkIctant wed:
2:Well Construction Perttdt 9: _-
fl3f idlltappllc0le t 1fJh niOdji,t!.Cuero Srsve•VdHi xx_llrjrntfUf,,Nde)JRlruwt+
7d.Atnount of.disinfectant used:;
3.��'dl usr(tlteti:n•dI ire): .
Niter Supply Well: 7c.Scaling myterials used(chi a i'all that apply):
pAsrirniglttttal. 17Mitnicip rllt'ttlilic Q,NcarCcnicdt:Gioiit ' tM sc1w1ori1w Chips or Pellets,
POW1Itcnn it(Hearin*,f C:'ooling supply') t]licsidcntilel Water�SippF)'[si»g1F) ❑5aricl Cetttcnl GtnGi `�4: � F]'T�lkctav
❑Concrcte'Gro'.�°`�"�'"i'"'" I"'IriI1 CLtlin
❑hidmitiol/Cotnnicrcial ❑Re0denii;tl'Water Supply(shared) Y3
❑rni tier ' O'spccirtltp Giaut O C T 0 G.2023 l7 Gravel
fioa=Water Spppl}«!ctt; -- CI 13enivtpte 51utry PJ Oifier(explain undi r7g)
®hlavitydvg- 13 Recotet_i'. r:v�I,titC.
injection Wc1h 7f.For each it atertal selff4vt#siVvOrovidq amount of:ataterlals used:
OAju[feritec[targe: �0rtiu»dviater"Retnedl:rtioir i.
OAgvifrr Stanrbe atilt Recov'ety ❑Salinity Darticr
❑Aijuifcr Test ❑Stdimt�'ater Dpli age
Bentonite.:500lb ,Wtr:gal.
17Expetinteittal Technology ❑$ubsirieuce Cuttttvl �
7y+ Prop tdc u hricf discriptiuti=of the abindnvmcnit prtte Wure:
00eodwrinal(ClosedI:oop) �JTracer
Backfilled boring w/ hydrated bentonite chips
®Geotherimi(Hcadnp'Coolin Retum) 00dwr(c>; lain under7u),
d.Date wcll(s).:ihandoncd: 9/8/23
5a,Well["cation:
Wix Filtration
TacilityiQtvr�rNattw ricilily WAI(k'applimbic) R•.Ccrtificatlou: .
1301 E..Airline Ave. Gastonia, .NC 28054. ~l'� rsJl+f+ G� 9/25/2023
Physical Addmss:City;avid Zip 5iritrint arr_,:;ilici!tiVeDt Coiuraelnt or W'c1l pi+t tc Dili*
Gaston If}:.si un�tkis frirm,.!lie;vbv.cerhfythgl the irfll{'s) trar(here)abandoned.in
Cn)inry, Pftrecl lJoAff"teat6h Not(PINj eir eviifirncc w1f,I.i:�'C-1C 0,�(',:0100 Ur 2C.0200,Well-Cotiitiiictfori'Slcnt kwds
andllrir(a mp);ofllris recurd ltarbeeil pruvkkillo7Jre.u•ell otriier.
Sb:.I�tti(u dc'aod lanfiitutfc:in.ctcgtxcs"Litilttufea/scinnds ar dxinril d4�;i+ces: ,
(i!'�pett Ca41,atiL tadlung:u b7ttD(cict�) 9.site diagram or additional well details:
You Mm .use the bar-bf this.page to ptoyidd additional%w1l.site detaiU:oi%trll
N �V aband0taueutdetails You tno}'alsi:lira*h asAiitio»aCMo s if wets, ty_
CONSTRil[G"PiOMDETAIL5(1NWt LL('_4RF_IRCABAND61VED St1R1►T(7TAi,iNS_TRUCTfUNS
:tffatit wel)cum enrlkaa rLew l(sa'ii'ava)Iralak. Fri*n:arhiple;iilrcrfrat+.Ur r✓Jimwler suppty i
icefh ONLY iridt lba serve e»leturaeiknc'attgrrihitaaern.1,0a ran sulrirdi acre fa m.
10a:.For All Welts: Suhtttit this faint'viittiia 30 days of cotnpictian of;hell
abandtfntitcitt to tlic ronviOn^:
6a.Well iD#:GTA-5 a.
DIVision of"Water Resources,Information Prucessing Unit
6b.Total 1FCU depth: 30 (fL} 1617 Afail S'crvice'Center,RAteigh,NC 27699-1617
fob.For IniKOwl WOR:.In addition to sending the form to the address!it l0a
abow.also subnul oue copy.of lltis fora vvidifil'30 days-of compteliou of vvell
6c:Borehole diameter l .
Ott') :ibdndonnntern to[lie.follolying:.
641.Water level bclnn•'n'oeind surfaeci (ftJ D[vislouof Wntcr Rcsoarcts',Underground linjcrt[ou Conlrul Prvgrata,
b 1636 Mail Service Ccnicr,Raleigh,N0 27699-1636
6e Outer easing Icn�h.(iE Imnn n); 20 (ft.) 10c..rnr Water Sunni'�c.tniectlnn«'e11A: In addition fo wading the fomt to the-address(es) abo�*. also subdiil;one copy of this form within 34 days of
cotupkiian of well abandontment!to;the county health deparinteta or the county.
Gf.Inner casinWtnbing te:nyKh(if tmaye'n)': (ft.)
where abaodoricd,
i
ft Screen length(if lanovvn)-10
r1 ,
Poor GWAO North Carotlm Depart" n oPEneirounient and Natural Rcsowces- t M OMMes Revised Aagw4 2013.-
I