Gaston_Well Abandonment_20240710 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well ontractor Information: WELL ABANDONMENT DETAILS
al\(eTV Clain 7a.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same
Well ContractQr.Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4
S Sc)—
A wells abandoned: 2
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 7 (gal.)
1' 6 q <,V c— Q CJ(,t` FOR WATER SUPPLY WELLS ONLY:
-Z:WWeII Co"siffiCtion Permit#:
--- - - - -
List all applicable well construction permits C.e.UIC,County.State, Variance,etc.)if—known G�Z
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout P Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Okesidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Im 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
❑Aquifer Storage and Recovery ❑Salinity Barrier Y`7
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geohermal(Closed Loop) ❑Tracer
❑Geothermal(HeatinglCooling Return) ❑Other(explain under 7g) C I y(a"Ve", Le, Rc`'2 J
o,�ce-
4.Date well(s)abandoned: " L` r
Sa.Well location: L)
3oS eS
Facility/Owner Name Facility TD#(ifapplicable) 8.Certification:
Physical Address.City,and Zip
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the wells) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lla``t/long`is sufficient) t 9.Site diagram or additional well details:
You may use the back of this page.to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
_CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well consavction record(s)ifavai/able.Formultiple injection ornon-watersupply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well 1D#: abandollment to the following:
�J Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1._0© (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter (in,) above,also submit one copy of this form within 30 days of completion of well
I abandonment to the following:
6d.Water level below ground surface: l (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (fL) 10c.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
6f.Inner casing/tubing length(if known): / (ft.) abandoned.
6g.Screen length(if known): ! (ft.)
Form GW-30 North Carolina Department of Fsvimnmental Quality-Division of Water Resources Revised 2-22-2016