Catawba_Well Abandonment_20231228

WELL ABANDONMENT RECORD IForinternalUseONLY:
I:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Cody.Dobbiris 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 eodstruction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4539-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 300 (gaL)
Catawba Valley.Engineering &Testing FOR WATER SUPPLY WELLS ONLY:
Company Name . 12.5% sodium hypochlorite
7a Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well constructionpermits(i.e.UIC,County,State,Variance,etc.)ifknown 1.0 liter
7d.Amount of disinfectant used.
3.Well use(check well use):
Water Supply Well: W.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public O Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single).. ❑Sand Cement Grout ❑Dry Clay
MIndustrlal/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
OIrn ahon - -B Specialty Grout-- -t7 Gravel=-
Non-Water Supply Well: ❑Bentonite Slung ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material,selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 2.0 cubic yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑Stomtwater Drainage
❑Experimental.Technology OSubsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothemtal(Closed Loop) ❑Tracer . . .
Plumbing removed,disinfectant introduced,filled with grout to surface
❑Geothermal(Heating/Cooling Return) ❑Other(explain under.7g)
. 04/07/2023 ���..•%o:S���1�1 .
4.Date well(s)abandoned. DEL!
5a.Well location: 1�
Catawba Firedepartment- lndrtia t: to W I" "
Facility/OwnerNam6 Facility ID#(if applicable) 8.Certification:
5715 Hudson Chapel Road, Catawba NC 12/19/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 378104740908 . . .
By signing this form,I hereby certify that the wells (Were)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.
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:
35.69807 81.06475 You may use the back of this page ito provide additional well site details or well
- `-N--- —- _W- `-abandoumen-rddt ails.-You may alsolattacchadditional pages-if necessary.- —.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBM TTA.L INSTRUCTIONS
Attach well construction ricord(s)ifavailable.For multiple injection ornon-watersupply wells...
ONLPwith the same cbnstruction/abandonment,you can submit one form.
10a. For All Wells: Submit this,form within 30 days of completion of well
6a.Well ID#• N/A abandonment to the following-
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 260 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (m) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
80 Division of Water Resources,Underground Injection Control Program,
6d.Water level-below ground surface: (ft) 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 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): (it.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016

NVELL ABAND.ONMEN.T RECO" rat Ncnml vs�ONLY:.
This foim m be used for single or multiple wells
1.Writ Contractor information;• IVFLL ARANDONNIENC DE1'AGEAf
Stefari Smith 7a.Number ofm ills beinRabandana�1
1Ve3tCoutwor Nam(or s%'IlonmrpusomUy Feu' n1d0i6le 11yedfair .or ron-ucrer! 'siijo, wells ONLY with the •stme
cmisrrtrcl7nn'47homini+ry ett,)rrry ctvr,rrhriUt wtejfrnn,
357357 6A � ,,
Yee.Cnnlmao�Cetlifcatioii Nntizbci 7b.Appn►zimate voluurc of water rent tiniug in ive11(sf
SAEDACCO FOR WATER SUwPPLY WF•GfS ONLY:
Cong an}Namc 7c Type of disinfee nQ u ed:0.
2:Wdl construction Permit 9: ,
Lido,amd""ublauelllurmiiv.(i.a,Ccetnty,-Stete,f'urtac�ce,fnJertion etc!1f'ttman . 7d .Ugiottntofd3sinfCCtsinttlSrVl:
3.�4'clt use(chc*Well use):
Water Supply With 7c Scaling mutcrisils used(cbcctt all Chat apliiyj;
lfrttgricllitttiat. 17Municipal/Public- 0 Ncat Ccnicut.Gmut O Bentonitc Cbipiefecilcts
17l rcpthctmtl(Hsating�Ca©lino$ripply) dI2csi&r0W%Vatcr-Supply(single) fientenl Grout q Dry Clay
❑btdustiiallCotnntc�ciat M sidcntial�VatcrSupply:(rAmrcd) ContietoGrotu 17 DrillCaltiii
❑Irti'•Lion O specialty,Grout 0 Gcwel
ikon\YaterSupplyWell: ❑Bentonim Slurry 0 Outer(explain under 7g)
t7lNmdtodng. 17Recovety
Tnjcction Well: 7f,For each uiaterial sc[Mcd above,provide aototifit•titaterials used:
OAquifer.Recharge, I7Grgtiiidaater Rinux iatiou
OAquiferStamgc aid Itccoveg' L)Saliniti'Ranier
❑AijoifeiTest. 13St6mnvat&D:niinage 3/8" Bentonite chips Amotuit:4 I
I7Exps rintecital Tcv:ituoiogv 17Subsideiro Cmdnrl fig,Provide a brief deceriptian of tic alm idunmeat pmcourm
OGeothennat(Closed Loop) OTracer
POURED CEiIPS IN 10" LIETS,•AI:7D HYDRATED.
i7Geothemx t(HeatinglCooli Reium) .• 190ther(m lain under 7R) IVED
a.Dakweli(s).nllandancd. 12-14-23 l l 4 2022
Marshall Steam StationDWOA
raoilitylOimaNam racili>i 1DA(ifgplicablc) li•cetRl(iritiou: OG
8320.NC-150 Terrell, NC 28673 12/19/2023
Pli}'sicat'Addrs.City;and Zip Wcil(hair D to
Catawba ft),-VO lrtg this I hereby certify that the irell(s)was(were)abandoned in
Collin)' Pttrce3li WifieidanNo.(PiNj amorr anw frith IS=fA1'C'AC 02C.0100.or 2C.0200 WellCorfslracam Sm"&mis
held that a cop}bfllris record 4m bein provicled to dhe is-all 6mior.
56:1 ltitude'and langitutto in stcgn ees(atimutcsfsecaarls'oc ilcd4,al d_ ' rccs: ;
(ir,%cu t'.;tit,one tallong:c 9..Site diagram or addidooat well de"Its:
35.59859 80.964427. You may use the bast:of Utis page to provide additional VeU site&mils:or well
N . W .abaudoiuuetti details..You stray also attach idditioiraf pages if.itec cssath'-
CONSTRitC' ON DFTAIL.0 nE WF.LLfRI BEING ARANnONFD SURNti TAT.INSTRL3MO1tiS
:tlfntlr u'e11 cnrssuarllr�rr rucurdls)'1J'OviJlm?Ja+. liir trrultiptr ilfedinn'W'rx+n•uutrr.wPf+lJ'
uofLsONLI rritflrhesvmuriursrnullmVnhairv4trinrnt)e�acan mhmltwtefuim 103:Far All Wcltc: Submit [his fotur viittrin 30 dt}s of completion of ilvell
&L WA @i•SVE-1 ablindoumcnt to t1h;to oW�rig:
Dlvimian of Water Resoured,infurinAtion Piamiing Unit,
6b.Toralivell depth: 10 ((p.)
1617 ALdi Seit ce Centel•;R'alci�li,NC 276994617
• tOU.Fnr in lectiart WcUs: )n addition to seeding tlte.fotnr,'tu the a'idiess[n_10a
above.also'submit oee topz;of this form Withiu 30 days of-completion of iwll
6c.Borehole diatt3etee:l (in.) nbiuidountent to'thc 001101.1jng:
lid.Water tevcl.bciow lnnuRd wcfacc 0 {ft.) Division of Waict Rcstinrecs;Updet gruitad iujecttae ConerirlFnigr:un.
1636 NUB Service Ccieter,lwa lr,XC 27,89-1636
6c,Outercaiing icn sir(if lnimu): ( .) fQc.ror'�yater Serials iiticettnia tYetuA; in addition'to.setdiug the form to
the address(es) above. also submit'bile copy of this form within 30 days of
comptction of ivdi abandauinnat rojthe county he dth department of the county
Gf.Iopine:tvinWtn6iul;Cwo6(if Camovvn); (ft.)
When;abandoned.
6g.Screen ken tit(if Wong):
Fenn OW-30 Nonh Cawtim Depanimm of Environment and N:ntaal RCsotmes-Division of Watcr Resoam s Rcviicd August 20t3
}