Gaston_Well Abandonment_20240429 (4)

WELL ABANDONMENT RECORD For 64crn 1 Use ONLY:.
This form cart be usm f6r.sittele or multiple wells
1.Well Contractor Information: )YELL ARANDONMENT DFTAILS
Brian Ewing . 7:i.Number ofivells being ahandonede 1
Wc1CCannrtctorNaoteorticlloen� tsanall tllalelanln;vvcilon5isllcr n For nitrlople. .oyealari er rmmitirerl aup'pdr. wells ONLY with Mv..imle
( p� S"'. t!r0t>c.9) caasfnrc�lrxa/ui6aircdaitna�eaf,}xineiersr+fviUt`�tejbrut,
4240-B
NC'tYdl CanlradorCenlf,5tioti Nurit6 r 71r.Arpnizimatc-yolnint gEvra(w remainiiig iii ivtll(s)t (gilt.)
sAEDAcco FOR WATER-SUPPLYWRLIS ONLY:
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ConpanyNams 7c Ty-)teofilisinfectantused.-
2.W`ell Construction Permit#:
L[,Y dell tippll,vLlr arfll<rmiir jL, Cuirnl,Sivie,Marlunre.l rJecr;m;,etc;}Pffinv>nn 7d eltrioutlt of JLcinfectsiut ustvl'
3..Well use(chec well use): ;
Water Supply Well: ?G Seating matcrialsmsed(check all drat apnlg)
17Agticnititral MMunicipatMuhlic M Ncat Ccmcnt.Gr= Q B-Cntonitc Chips ormilcts
QCkotliclmv (Hc rlincgCoolino Srrppt}'} . pkcsidcMinl lVatcrS�rpP$'(pnglc) ❑Sand Centenl Grant ❑.Dy Ctay
0htdush611ComntctcW ❑Residential W ttcr Suppf}'(sliatid).. ❑Conerele.Grout J3 Drill Ciatings
❑Irti lion 0 SkLjaltyGrout ❑,Gr�rel
Non WaterSupplpWell: ❑BentotticeSlutty d Other{erplain under 7gj.
I monitoring... ❑Recoven-
lojcetion Welt: X For each taaterial selected above,provide amount ofaiuiteriats need;
❑Aquiferitccharge_ ❑GrottnduaterRentedWon Neat Cem.:471b ,Wtr:3gal. Sand Cem.:1b ,Wtr:ga1.
❑AquiferStotage atxl Reeos'ery OSalinity Barrier
❑Aquifer Test OStonmvaWrDrainage .
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❑Espelintenital Ttxlmn[ot�n ►]Subsideuct Conbtul 7pr Provide a brief'descriptian of the wind mment pn!&-#ur=
DGeolhennal(C1o5ed.Loop) . ❑Tracer I "
TREMIE GROUT FROM.BOTTOM TO SURFACE
®Geothemval(ii6lint11C00[inR Retum) QOther('es lain uttder 7 )
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a.Date:wcU(s).alvuniloned: 3 `6�.'�_..•.�.�r t,f
ia.Well location: APR .c�� S-2024
Four Points 76 IDb F �—
R.CcrllRcadan; F• ^2 -10
Fatilit}•/OivtrrNuatc a.ilitvv (fupplicablc) - 1 lThti,;r„o;s;1
1702 Hickory Grove Rd. Gastonia,-NC 28056 Brian Mi d��`���/2024
Plty'sical Addrua.City,and zip S�ahtrcort enificd;Nell Cotur,astr<,r�'.II(hvtur Date
Gaston County 1iy sighing skis farts,1 hemby certify rkat Ilea irell(s)irac(mein)ahandoned in
Cauttiv %reel ld.lirilSclko No.(PIN) rrrxvn&rtice ivilh l M.-MCAC.02C.0100.ur 1C.02001['e11'Gari�lracliun Sfrirukr►rts
and that a Copy 0fltri5!record has been provided to the trell sillier.
Sh.Jztkude and Nngitade In degi+cesrminute0seconds or dccimal'dcgrecu
(irwen rvkf,om.IiOF ag iv sitlriexrx) 9.Site diagram or additional iv'ell detalls:
You ttitt3'-use.tbe bade of Wis,page t'provide additional well site.def i[Is:tir-vvell
N - W ,abaudoiuuentdetails.-You may also attach asldiiiouaf pages if ltecessan'..
.CONSTRIICMON DETAILS OF WFLt�.%BFINC ABANDONED SUBNtTTTAi,mSTRL.CTI.O 1S
:[Itatlr v:ell.carytracflcut raivrdlsl rj ava(lwli. Far muloplr ilJrctiwe'ar Tian-uvti7 snEply
celleOIYLY'tritflrJrNsvnrecwrsarxnmdrupntlUf;rtMir.ioumn ndinticurelymr 10a.For All Welt,. .Submit thiv form-nithin 30 days of completion of u-cll
6s.Well ID#•TMW-7 'abandonment to'thcfallowing:
Divi lion of Alater Resnnrces,Infolmation•Procesiunr,Unit,
Gb.Talal well depth: 25 {ft.) .1617 Mail Service Center,Raleigh,XC 2 G99-1617
10b.Por.Tnleclion Wells: In addition to sewing the fotni to ilia address in l0a
above.also'submit one copy of this f rin vAdiiu 30 days of•completion of well
Ge.Borehole diameter:l (ID.) abAndonntertt to tine follaysing:
fie.Water tev'cl.belan anti surface (ftJ Divis[ott of Witter Resources;Uttilergruund Injeci[on Conlrul•Pragram.
1636 Stail Sciviec Center,ltalei;,h,1\C 23094636
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Gc.Outcrcasinglcngth(iflmnpn): ( .) Lac For jVjter.&rjriIv A.Infectinoi Welty: In addition to-sending the fomt to
the.addre§s(es) abode."also subnut Dire copy of this fotnt Nithin 30 days of
completion_of vvcli a6ndoiunent to the county health depannient of the county
(of.Inner casin/tubing truktb(if[mown):
where alnndoncd..
Gg.Semen length(if known):10 (tY.)
Faint MI-30 NaFth Carutim Depsorncol OfFEPvlronnlent aW Mqumt Rcso N-Dlvidon of Water Reso b,si Pevi cdAagusn 20 t3
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