Gaston_Well Abandonment_20240603 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Con *"Information WELL ABANDONMENT Djd�AIIS
on { 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her prnpetty) well construction/depth,only I GW-30 is needed Indicate TOTAL NUMBER of
wells abandoned:
NC Well Cotmacmr CM cation Ntmtba 7b.Approximate volume of water remaining in well(s).
i FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit vlc
List all applfeable well consavcnon permits r.e"UIC.Co—ly Stare,t/—e etc)ff,bimvn
7d.Amount of disinfectant used: � i
3.Well use(check well use):.
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑M cipal/Public ❑ Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(HeatingtCooling Supply) pResidential Water Supply(single) ❑ Sand Cement Grout Clay
❑lndustr al/Commercial ❑Residential Water Supply(shared) 0.e6icrete Grout ❑Drill Cuttings
olrrigaton ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry O Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Welh 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
-'Aquifer Test IDStormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) OTtacer 7g 77n;
Provide a brief description of the t procedure:
❑Geothermal(H Coo M Return) -'Other(explain under 7 ) ���� Ll• ���
4.Date well(s)abandoned: ~l JD `-2 /
5a We
J i
F M#(ifapplieable) S.Certification:
City,and zip Sil;ww a ofcerns wen to or well owner Date
7
r'4 ZG ,i By signing this form, 1 hereby certify that the well(s) was (were)abandoned to
County Parcel Beatification No_(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
fib.Latitude and longitude is degttes/minates/seconds or decimal degrees:
(ifwell field.one lat/lon is sufficient) 9.Site diagram or additional well details:
N w You may true the back of this page to provide additional will site details or well
abandonment details. You may.also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELDS)BEING ABANDONED SUBMITTAL INSTRUCTLOI!6
Aaach well won newrd(s)ifaaazlab&Formod4vle u jeeoon ornon-waterssrpply wells
ONLY with the sonreconstrrrrmn/abmdormeent,you can sabnriro+uform 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well 1D#: ✓-'1 f abandonment to the following
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (R) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter. c< ! (ia) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following
6d.Water Icvd below ground surface: � "/CJ�t E (ft.) Division of Water Resources,underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e-Outer casing length(if known): (ft,) l0c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner asiog/tnbing length(if(mown): A fL) abandoned.
6g.Screen length(dirnown): /l/ y 0 (ft)
Form GW-30 North Carolina Deparuwnr of Environmental Quality-Division of Water Resources Revised 2-22-2016