Gaston_Well Abandonment_20240116

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Inform do 9 WELL ABANDONMENT DETAILS
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` . ' 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
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in wells):P(gal.)
w� FOR WATER SUPPLY WELLS ONLY:
Com an t
P y Name 7c.Type of disinfectant used: I J7 `G
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2.Well Construction Permit#: ;
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown li
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 �, ;!B tonite 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
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry j ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Ll"LA jn& /�
❑Aquifer Storage and Recovery ❑Salinity Barrier / '
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.provide a brief descr'ption f the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) El Other(explain under 7g)
I o r + C
4.Date well(s)abandoned ', u t t Vf
5a.Well location:
y 8.Certifi lion:
Facility/Owner Name Facility ID#(if applicable) JTTsv;r,-c:{i£il p7�n;..a:>i0,r•� I r?,
PhysicallAAddress,City,and Zip a�b Signature ofCertifi d Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A 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:
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
Attach rvell construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
B 10a. m For All Wells: Submit this for within 30 days of completion of well
6a.Well ID#: abandonment to the following: I
Division of Water Resources,Information Processing Unit,
6b.Total well depth: .?1 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1619
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: Cil . above,also submit one copy of this form within 30 days of completion of well
(in)
(i abandonment to the following:
6d.Water level below ground surface: v VAH (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.For Water Suoniv&Iniection''Wells: In addition to sending the form to the
addresses)above,also.submit copy of this form within 30 days of completion
/n� of well abandonment to the county!health department of the county where
6E Inner casing/tubing length(if known): h14 (ft.) abandoned.
6g.Screen length(if known):
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016