Catawba_Well Abandonment_20231204

WELL.ABANDONMENT.RECORD For lotemal'Use ONLY:
1..Well Contractor Information: WELL ABANDONMENT DETAILS
Daniel Summers 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
2579-A wells abandoned: 1 C.
:4:80
NC Well Contractor Certification Number 7b.Approxiinate volume of water remaining in well(s):.• .(gal.)
Carolina SOIL•Investigations,ILC FOR WATER SUPPLY WELLS ONLY:
Company Name: ..
7c:Type of disinfectant used:
2.Well Construction Permit#:
List all applicable tiveU construction permits(i.e.'UIC,.Comuy,State,Variance,etc.)fknoivn
7d.Amount of disinfectant used:
i Well use(check well use):
Water Supply Well: - - 7e.Sealing'materials used:(check all that apply)
❑Agricultural;:. ❑Municipal/Publi'c a Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heaung/Cooling Supply): OResidentialWater Supply(single) ❑Sand Cement Grout:: ❑Dry Clay:.- -
❑Industrial/Commercial- CResidential Water Supply(shared) ❑Concrete Grout" ❑Drill Cuttings
DIrri ation ❑'Specialty Grout ❑Gravel
Non-Water.Supply Well: ❑Bentonite Slurry. ❑Other(explain under 7g)
CMonitoring ❑Recovery.
Injection Well: 7L For each material selected above,provide.amount of materials.used:' .
DAquifer Recharge DGroundwater Remediation neat cement 174'IbS,"(per viiell)
❑Aquifer Storage and Recovery: ClSalinity:Barrier., ;
I
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology. []Subsidence-Controh . .
7g.Provide a.brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)• .
tremie grouted with neat cer',nent:,i
❑ s
1'0'30-23.
4.Date well(s)abandoned: J_ -
5a..Well location: + ,: :�_.,.i.,,l?;•rr.;.,^:.� t�F::.
• `sP"Y3�s.. - it^-. 'la
Lenior Rhyne College (Maintenance Bldg).,
Facility/Owner Name Facility 1D#(if applicable) . 8.Certification:
643 8th AV&NE' Hickory, NC
� Q (� 10-30-23'.
Physical Address,City,and Zip Signature of Certified Well Contractor or Well:Owner, Date
Catawba. B si in this form,'I hereb.ce' that the.wells.was were abandoned in
. . y. s� g I y Iv l)- (were)
County Parcel Identification No.(PIN)'.' accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction'Standards
and that a copy of this record has been provided to the well owner. "
56.Latitude and longitude in degrees/minutes/seconds'or decimal degrees:. I
(if well field,one tat long is sufficient). 9.Site diagram or additional well'details:
35.74134. -81.32417. . You may use-the back of this page to provide additional well site details or well
N W- ',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-watersupplyml(s
ONLY with the same constructionlabandonthent,you can submit one form.
10a. For All Wells:. Submit;this form within 30'days of,completion of well
6a..Weil lDll: DW-1 abandonment to the following:
-Division of Water-Resources,Information'Processing Unit,
6b.Total well depth: 60 (f ) 1617 Mail Service Center,Raleigh,NC 27699 i617
lob.For Injection Wells:'In addition to sending the form.to the'address in 10a
.
6c.Boreho le diameter:
(T Well) above;also submit one copy of this*form within 30 days of completion of well
abandonment to the following:.
30 Division of Water Resources)Under ground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC.27609-1636
r
. Na '10c.For Water.Suaoly&Iniec6on Wellsi In addition to sending the form'to the
6e.Outer casingleogth(if Imown): (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): (tt) abandoned. ;
6g.Screen length Of lmown): n/a (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016