Gaston_Well Abandonment_20240325

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information: WELL ABANDONMENT DETAILS 1 - • . ', - " -
John W. Huneycutt 7a.Number of wells being abandoned H'�' •
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water `supply wells ONLY with the same
construction/abandonment,you can submit one form.
2465-A • ' I
7b.Approximate volume of water reutaining in well(s): 720 (gal.)
NC Well Contractor Certification Number I'
Derry's Well Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name le.Type of disinfectant used: Granular
County did not require a permit but was on-site for abandonment
2.Well Construction Permit#: is '
List all applicable well permits(.e.County,State,Variance,Injection,etc.)iflotown 112 lb.
7d.Amount of disinfectant used:
- 3.Well use(check well use): - •
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- Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural •❑Mtinicipal/Public 0 Neat Cement Grout . ' 2 Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) :OResidential Water Supply(single) • 0 Sand Cement Grout 0 Dry Clay
IZ]industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout , : 0 Gravel ,
Non-Water Supply Well: El Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 6,100 lbs-,Bentonite Chips,
❑Aquifer Storage and Recovery ❑Salinity Barrier 200 lbs.- Bentonite Slurry .
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: .
• ❑Geothermal(Closed Loop) OTracer Well was gravity filled with bentonite chips from
" ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
bottom up-to 50' below surface. Remaining 50'
4.Datewell(s)abandoned: 12/21/23 was pumped through a 1'"'tremie pipe extending down
5a.Well location: in to well.
Duke Energy-Allen Fishing Station
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
425 Hot Hole Rd, Belmont 28012 :t?J fi 1/3/24
Physical Address,City,and Zip • Sign a of Certified Well Contractor otOgell Owner Date
Gaston ' '
. By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constntctio»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 latilong is sufficient) 9.Site diagram or additional well details:
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.
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CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
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Attach well construction record(s)if available. For multiple injection or non-water supply -
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
/�, // �on 9 abandonment to the following:
6a.Well ID#: �V� Lt?CX 1 �c`�,�'t�'' 9:s��� g
�'"��" ��9..,, Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 500 (ft.) MAR 2 5 2024
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6 irt%rw (:leaf aPr,17%,15a Jove,also-submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) IW(,}j3, r •a4 andonment to the following: '
6d.Water level below ground surface: 20 • (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
• 10c.For Water Suuuly&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): 104 (ft.) the address(es) above, also submit]one copy of this form within 30 days of
completion of well abandonment tOhe county health department of the county
where abandoned. l
. 6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources 7 Division of Water Resources Revised August 2013

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# 9—Well Diagram 6'�Well Diameter
No Casing
., ...
.. ..
Removed
^^^^ 0' to 50' Pumped with
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�^^ Bentonite Slurry
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Casing Depth — .
104' .
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50' to 500' Gravity
Filled with .
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Bentonite Chips
500' —Total Well Depth