Catawba_Well Abandonment_20240205

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well ContraZ&''e
frmation: WELL ABANDONMENT DETAILS
Q 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abafidoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Cettifi n Number ;~' - 4''� IFv d 7b.Approximate volume of water remaining in well(s): r� (gal.)
1^'
R . FOR WATER SUPPLY WELLS ONLY:
Compaq Name
7c Type of disinfectant used: J
2.Well Construction Permit n ' "` " U V
List aQ applicable well construction permits C.a.UIC,County,Srate�'`Yariaiiee'Oela)if known
7d.Amount of disinfectant used: �U 2
3.Well use(check well use)::
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑M pal/Public ❑ Neat Cement Grout ❑Be nite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ❑ Sand Cement Grout Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) oncrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: X For each mdlimat.selectedabove,proAdc smountof materials used:
❑Aquifer Recharge ❑Groundwater Remediation / /
❑Aquifer Storage and Recovery ❑Salinity Barrier
G/e,,l /
❑Aquifer Test ❑StormwaterDrainage _� /I c r—
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Coolin Return) ❑Other(explain under 7 )
4.Date well(s)abandoned: vp�
5a.Well location-
IleIJ'l r'L
Facili /Owner Name F ilitylM-0fapplicab1e) S.Certification:
Physical A f(� ,City,and Zip Signature o CertifiedLWell&Contractor Well Owner Date
c - a By signing this form, I hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with I SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
('£well field one lallong is sufficient) 9.Site diagram or additional well details:
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 SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavoilable Formultiple injection ornon-watersupplywells
ONLY with the some cons7VoA
n/,bandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
t Division of Water Resources,Information Processing Unit,
6b.Total well depth: • 5 (fL) 1617 Mail Service Center,Raleigh,NC 27699-1617
w 10b.For Iniection Wells: In addition to sending the form to the address in I Oa
6c.Borehole diameter: v _(in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
i
6d.Water level below ground surface: (ft) Division of Water Resources,Underground Injection Control Program,
- 1636 Mail Service Center,Raleigh,NC 27699-1636
6e Outer casing length(if known): /"r (fy) 10c.For Water Suooly&Iniection Wells: In addition to sending the form to the
addresses)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
6L Inner casing/tubing length(ifknown): On�J . (ft) abandoned. If ;
6g.Screen length(if known): 40n e (ft)
Form GW-30 North Carolina Department.of Environmental Quality-Division of Water Resources Revised 2-22-2016