Gaston_Well Abandonment_20240429 (2)

WELL ABANDONMENT REC01W I'm Inicriml Usd ONLY; j
This form can be used for single or multiple iv"lls
1,Well Contractor iufnt'ipation: WELL ABANDONMENT DETAlt 4i
i
Brian-Ewing 7a.Number of%sells being ahandoned�. 1
5Ve1ECoP�eaetorNaars(ar«�llo�rn,7p�rvonally alianlanbigueElunlrisil�rpiopcnyl for r 1dople. fiveafm or r,+omJ wurarj mpirdr wells- ONLY with Nee-.same
ffi'UfrrfCfhNl'o'1�10fh1tNiFth7lf,)YJP!C[vP rlh2Jllf�G1�ti,JFJrlJL
4240-B
r 71r.Anprnximate volume of stater remairmag in wrll(s):_
NCi�cUConttagorCaniGcali onNnn:6cr ,
sAEnAcco FOR 1VATER.:SUPPLY WEi.xS ONi.Y;
Carrg+arq Namc 7a Tyyje bf diainfixtant uzcrl:
I
2.NVeltConstavctimt Pertuit N:,----'-- _ _ -- ---- _
List 641 a1Jphe able uellpurXAV(i,e,.CuJrw,Su•;,,l'urlarne,Lyertirm„40!fkw s•n 7d,AidjAttntuf d]SitSfeCt:ttll used
S.Well use(eheck.q ell use):
W ater-Supply Well: 70.Scaling materials used(check all ibat apply):
❑rtgritnititrat pblttnicip d1Pt11ific N Neat Ccnient.Grout l7 l3entonitc Chip:orPcllels-
13(ieotherm ll(HcatingCooling$apply) QRcsidtntittt 14;7tcr )rppl5 (single) . ❑Sand Celuenl Grant ❑.Dry Clap
❑hrdoslreillCamntcrCial ❑Residential Water Supply(shared) ❑Couctete Grout ❑Drill Cuttinps
❑itti tiau ❑Specialty Grout ❑Gravel
Nou-\Pater Supple Well: CI Bentotule Slum, ❑Other(e_cplaiaunder 79'.)
29Munitorine ❑Recovery.
Injcc-tion Well: X For each material selected'above,providc aptourit of tivaterials used:
❑Aquifer Rccttarge ❑Griiuird%%glee Renrcdi uian Neat Cem.•471b ,Wtr•3gal., Sand Cem.•lb ,Wtr:gal.
OAquiferSlonrge atxl Reco%•en' ❑S:dirdty Oamjer
❑Az)uifrr.Tdst ❑SlammtnterClrafrafgc '
❑Ell�rcrilneulal Tecbuotogl� ❑Subsidence C jkml 7z Provide a brief description of the abandonment prom-lbire:
❑Geolliennat(Closed Loop) OTrace[ TREMIE GROUT FROM BOTTOM TO SURFACE
®Geothermal(Hminl�'Cdo ling Return) C1Uth,:r(es lainunder7tt) . _
4.Date well(s).aliandnncd: 4-2-24
Sa.Well location:
Four Points 78
rad1il)VC4vlu r Nar¢c rmilily ID41(ifupplicabic) A Certification:
1702.Hickory Grove Rd. Gastonia, NC 28056 -Brian_.E'1n�1. 4/5/2024
hysieal Address,City;and Zip $igrcrint�aif 4eitifukl\4'e11(Xugrr;laf �f:IIYJ,vr r i7a1e
Gaston County HysAgnipq ihis farm; 1 hereby certiA,duct the ireN(si rrvc prerer abouidoned ur
Courriy Parac]Id.nti[icillm No.(PlNi ouvrdance with 1 :1 K-i1C 02C,01a0,or 2C:0200 IP'e :Conde ecdois Sknukui7s
rued thal a crpyofthfs recurd leas•been proideled to ilia well onner.
5h.I nitude and longitude in dcgrceslminnteslsecon+ls or dcciural degrees:
(ifcscU Wd,pre;kJtltrino is 4.Site diagram or additional well detalls:
You tua}'use the bac):of this page to provide additional ticIefl site details or%tell
1\ W abaudoiuuent details.:You ma}-also attach nrldifional peg;s i.IIeCessary_
CONSTRUCTION DFTAILS t)F WELL(SI BEING:ABANDONED SL RMI-11-YAI.tN'STRUCTtOYfi
-W=6 Vell commmelkirJ ricvril(s)1f uvWlrlbj Fix=jIlple it erficn'ur ri�n•nv:ir supplj•
uriLr[?,PLY❑lfhthasrnJierwrstrrrcftalc'nrmr[1er:sP�rJf,re;umusrrhmncore net IOa:For All Wells:' Submit 11tE5 far%rt tiithiu 30 da}s of carnplctian of%%ell
6a.Well ID#:TMW-i abandonment to tltc'falloiAng;
i
Diyislan of WratcrResourck,Information PrucPssing Unit,
6b,Tntat%%•cll depth. 3o
1617 Mail Seivice Ccatc,r,Raleij h,XC 27699-1.617
(ft.}
lob.Tordnlection.Wells: ha additionito'sendiq,.tlk-.Coral to the 0(itess in loa
abo%t,also Sttblttll one SUpV of this fo'rtn%cidtiu 30 days of•cmuptetion of ur.0 -
6e,Borehole diameter:l (iu.) abendoturtem to lire fallativing:
DivislottoeWnterResourris,Uatletx;r4utid injection CoultiA Pttigr.
6d,Water lecelbelow ground surface:. (ft.) 1636 Mail Sendce Cente'r,lialeigh,NC_27699-1636
6c Outer casing Icnh(if Imps n); (ft:} lOc.rnr Warr
Wre wStrnnlc.4.Tuieetinn ns: In addition to sending the form to
Cite address(es) abo%re. also subnut one copy of thus form within 30-dajs of
comptctiori.of well abandoiuncnt to the wimty lwattb depanntcrd of Ilic county
6f.Inner casiup:Jtnbin;;lcntrth(if known); (tlt.)
whcro atrandotrcd,
I
6g,Screen icn(,Hh(if kuot%n):10 A) S
Fomr G%1`40 Numb Camtim Dcpannrcra ofEnviromment atsl Naluml Rcsomkes-Dh isiosr or NatLr Resou I i Rai lied August 20 t3
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