Catawba_Well Abandonment_20240325

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Alfred Kieslin Jr
g 7a.For Geoprobe/DPT or Closed1Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hisfher property) well construction/depth,only 1 GW 30 is needed. Indicate TOTAL NUMBER of
3266-A wells abandoned: S
NC Well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): ✓^�0 (gal.)
B & K Well Drilling Inc FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorine
7c.Type of disinfectant used:
2.Well Construction Permit#: af� 40K 1�1 f b
List all applicable well construction permits(i.e.UIC,Corn: State.Variance,etc. t known i
pp . p h. )f 7d.Amount of disinfectant useld D V
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3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 8<entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) i�Oncrete Grout ❑ Drill Cuttings
❑hri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation /J/b 41z 5 2 14 0 V
❑Aquifer Storage and Recovery ❑Salinity Barrier —+
❑Aquifer Test ❑Stormwater Drainage G`
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandon ent procedure:
❑Geothermal(Closed loop) ❑Tracer O tJt� I rG
[]Geothermal(Heating/Coohng Return) ❑Other(explain under 7g)
4.Date well(s)abandoned:
5a.Well location:
&in s 11 h 1,4 tar A561, e
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
J_ g,
Physical Address,City4And Zip Signature o crtifi WelIX5botlActo or Wel O Date
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� "(P 7,/l t�7 t5'!C3'-� B}+signing this form, I hereby cert t the wells) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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: P
(ifwell field one laUlong is sufficient) 9.Site diagram or additional'vrell details:
You may use the back of this page to provide additional well site details or well
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abandonment details. You maylalso attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ijavailable. For multiple injection or non-watersupply 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
6a.Well ID#:
abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 5 (ft.) MH n c - 2014 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: inladdition to sending the form to the address in 10a
IITCi;;r;r;L;� r�.,,=T above, also submit one copy of this form within 30 days of completion of well
a
6c.Borehole diameter: - (in.) f�' `�'f xa u
G`�lJ��,JC3 ' '�d`bandonment to the following:
'j Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: v (ft.) 1636 Mail Ser�vi i e Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water SnpPIV&Iuiection Wells: In addition to sending the form to the
address(es)above,also subrriiti one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (g,) abandoned.
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6g.Screen length(if known): (ft-)
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Forth GW-30 North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016