Gaston_Well Abandonment_20240429 (3)

NVELL ABANDONMENT RECORD iUsdONLY;
This farm can used for"singte or nlulOpte i ells
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1.Well Contractor information: WELL ABANDONMENTDETAit_S
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Brian Ewing 7a.Number of+tells being abandoned:
1
Welt Contmd rMuie orwcltowa� rnanall tlianiritdnewc0onhiseltsr ru n' Fir niglople, r/rferrla)e .o . M114%]ret sop'lxfr xeUs OVLY will) MW .same
c . l s u lx.y) !.:
• cmtstrrrcowi,'a�bairclanr)a�*r)r,�un cme.a+tNiUe w�aforzn,
4240—H
71t.Aplinii mate colufnc af:tratet•remaining in ivell(s):;
NC'�YcgCbnlmaorCcttlfiGllioiiNnrit6cr
SAEDACCO FOR WATER SUP1'LlrI1`R LS ONi,.YS
Con�aq+frame 7c Tyre I'dilisinfi'ctant used:
2:W&Caustruction Permit#:,
714u11appG�vldeue!lpu,rdar(i�C,n,nlrtSr,)to•1'artarm.L�rruon..re}tjlGmwn 7d:Amount of'disinfectunfuseti:
S.Well use(cbF"ell u.+e):
Water Supply Well: 7e.Sealing matcri:tlrlrscd(dicett al t ttiat gpply):
❑Agricnitttt tt ph9tinicipa1111"tthlic M Neat Ccmcnt.Grout Cl 13critoaitc Chips or Pellets
n0collicrinal.(Beating Coolin g supply) r3kcsidomial WaterStrpply(single)
❑Sand Cement Grout ❑Div Clay
❑buGistriallCnnmurCial ❑RcsidetuLA%Vatcr$)apply';(5h'red) D Con)tetoGrout. Drill Cuuin�s
I7ifd' [IOt1 ❑Specialty Ghoul i 13 Gravel '
NORAVater Suppty Wc1h, C1BentouileSluny 0 Other(espiainunder7$)
119motdtoring.. 131tecocety�.
Injection Well: 7F.For each uraterial selcded above,provide amount of tnaterials used;
❑Aqutfer.Itecharga OGroundualerltentediition Neat Cem.c471b. ,Wtr:3gal. 1 Sand Cem.:lb ,W,tr:gal.
Dtlquifer Storage and lteeovety ❑S:dinity Barrier
47Aguifcr.Tcst OStornmatmDr tuage
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OE.gterintenlal Technology 17Subsiden a Cmrtrtil 7g PtutI&n bruf descriptian of thc_ubandonment nrbcedunn
t7Geeihennat(Closed Loop) ClTracer
TREMIE GROUT FROM.BOTTOM TO SURFACE
©Geathermat(He tlinRlCoolin Retuml C3Olher(explain undef 7gl
4.Datevtell s ahandoned: 4-2-24
5a.Weil'tucations i AP k 2 N 1074
Four Points 76
Faciliryia}n'txr Name Fa illty IDs(ifapplicablc) ti:Cet111lcatiaU: i , ��-f U.eI
1702,Hickory Grove Rd. Gastonia,.NC 28056n_ Evi n °+4/SJ2024
PIt+'Sleal Address;City,and Zip , �Siunrhrn;irl'Ccitil'uti11b'etl C�ntra.tardF U.2te
Gaston County y sittttg this frn7n;1 hereby certify t1)itr the tre11(s)u'as(irere}abandoned irr
Conuty ouv►dinttre With 1MAU1C.02C.0100;vr,3C.0200111HI.CotisfrvaionSwruk)rxls
and drift v crp}r0j11tis reeard h&he'en pravid&fo the nell owner.
5b.I atitude and 16ngitudc in degmeslmimtteslseconds ordednial-degmest
(ifd ell rod,one latMis is sriilickt') A.Site diagram or addittouat vt'ell det:t[lsc
You rua}-trse the bad:af`this,page to liroiide addiliollai itYll site.derails or'isell
N W ,;tbntuloiwterddetails..You tuap also ailath'ndtlitiona(pas if t1CC28586i'..
CONSTRI11.MON DETAILS OF WEL651 BF1NC ABANDONED SUR11ti7TAi.iNSTRQCTiOYS
.ttrarh trdl.ciorzxtrtrcticur ri%vrJls?tf a+ralrUla~ ,cru•tntrltiplr iil�crian'ar rr�n-nvtir suEp(r -
u e11.s ONLY with tl>a s,rm�c»nstrr)etiolrrzharulatrrnc�)L iia inn n,bnitt_cur)jyrrir 10a:For All Wells: Submit ibis femi within 3o day5;of comolction of.will
Gs.Well ID€ISTMW-6 abandonmcut to the following;
Diy'ision of WaterRe6urces,Infor nation•ProeL-Ling Unit,
25 1617 Mai ScRiCC Ccntcl;Ralci;,6,XC.27699-1617
6k Tetalivell depth: (ft.)
IOb.For inl eel ion WON: Ll addi.ioil'to sending Ilia form tp ilia address lu.10a
Gc:Bor�liolc diauteter:i (lu,y above.also submit one cape of this fo ni,within 30 days of completiofi,of hell
ubindomind to;dw tollowitt :
Digistou;of Water Rssuurces;Undergnmiid bijectiom Contfol Prdgratu,
Gd,Water levelbcton grauud surface:. (ftJ
1636 Mail Sen'icc Center,]talci--hi NC 2 7 649-1 63 6
6c.Outer casing length(fflmown): ( .) Me.Far MterSurnilv'&ioicctioei Wetts: 1naddkion'to•s.ndhig the footto
the.addres(es) alcove. also subtuit one copy of this form within 30 daj•s of
compictiori•of nc11 abmndorunent to the`ebiuuy he6[th department of the county .
where abandoned•.
GL inner ensingltubing tength(if lmow•n); (ft)
f
Gg.Screen length(if hnown):10
Fame M,40 Nanit Canothn Depawncm ofEn0mnmmnf:wd Muumt Rcsomes—Dlvisiasrof VAterftcsoiLx s Reviled Augus12013