Catawba_Well Abandonment_20240119

WELL ABANDONMENT RECORD
FInteFor
rnal Use ONLY:
1,Well Contractor Information:
WELL ABANDONMIsN'I'DFTi1i1 S
NEILL PARDUE
7a.For Geoprobe/ hill or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/har property) well construed ii/depth,only I GW-30 is heeded. Indicate TOTAL NUMBER of
26O9A wells abandoned:
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NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): il.
AIR DRILLING INC _(gal.)
FOR WA'1'I';R SUPPLY Wh;LLS ONLY:
Company Nat ra
11-2023-208895 7c Type of disinfectant ttse/l: HTH
2.Well Construction Permitil: �
List all applicable well consn•uclion permits(i.e.U1C,County,Slate,Variance,etc.)ifknown CUPS
P C
7d.Amount of disinfectant used C V S:
3.Well use(check well use):
Water Supply Well: 4
7e.Sealing materials used(check all that apply):
❑Agricultural pP Y)'
❑Municipal/Public 11 Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) aResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial []Residential Water Supply(shared) X Concrete Grout
❑ Drill Cuttings
❑irri gation ❑ Specialty Grout
Not-Water Supply Well: p Y ❑ Gravel
❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7G For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Reniedintion 5 YARDS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Pest ❑Storniwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal Loop) 7g.Provide a brief description of tine abandonment procedure:
( P) ❑'!'racer
❑Geothermal(Heating/Cooling Return) ❑0ther(explah.i under 7g) POURED 5 YARDS CONCRA_TE
fnv ^'-1���P J IFere
4.Dale well(s)abandoned:
12-18-23 ''
Sa.Weli location:
TODD SURRATT
Facility/Owner Name Facility IDlt(if applicable) 8.C t ion:
3778 DOCKSIDE LANE,SHERRILLS FORD,N.C. 28673
r 12-18-23
Physical Address,City,and Zip Signature of Ccrtiftcd Well Contractor or Well Owner Date
CATAWBA 460701458136
County By signing this form, 1 hereby cei9/%y that the rvell(s) it-as (were) abandoned in Parcel identification No.(PIN) accortleince with 15A NCAC 02C:0100 or 2C.0200!Pell Consb•aclion Slandartls
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of!his record has been provided to the wen owner.
(if well field,one lattlong is sufficient)
81° 00.121 9.Site diagram or additional well details:35035.298
N 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
Allaehucileo�+slrurnnnrecord(s)iJavrti(able. lorwtdlipleinjec(ionortinn-wtticrsupph'wcll.� SUBMITTAL INSTRUCTIONS';
ONLY tvith the•canto cat.vYraclion/abaneinnatenl,you van subatit onef ral.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well 1D#; abandonment to the following:
6
Division of Water Reso'Urces,information Processing Unit,
Cb.'1'otai well depth: 35 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
24 INCH lob.For Inieclion Wells: In addition to sending the form to the address in LOU
6c.Borehole diameter: (in,) above, also submit one copy of this form within 30 bays of completion of well
abandonment to the following:
6t1.Water level below ground surface: (ft.) Division of Water Resources,'Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
fie.Outer casing length(if known): (ft.) 10c.For Water Supply Sc In'ecli n+Welis: 1u addition to sending the form to the
address(es)above,also submit onei copy of this form within 30 days of completion
6f.inner casing/tubing length(if known):
of well abandonment to the countly health department of the county where
(ft,) abandoned, I
• I
6g.Screen length(if known): (ft.)
Form CYW-30 North Cnrolina Department ofGnvironnicond Quality-Division or Water Resources
Revised 2-27.-2 U l G
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