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Home My WebLink AboutGaston_Well Abandonment_20240903 WELL ABANDONMENT RECORD ForintemalUseONLY: 1.Well Contractor Information;/ 1VELL ABANDOKMENT DETAILS R1�I Lk a r'A C G0 L e Wte4 N 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Well Contractor Name(or well owner personally abandoning well on his4wr property) well construction/depth,only I OW-30 is needed. Indicate TOTAL NUMBER of wells abandoned: NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.) FOR WATER SUPPLY WELLS ONLY: Company Name 7e.Type of disinfectant used: L I e P.f.- 2.Well Construction Permit H: List all applicable well construction permits(t.e.UiC.Coat%Stare,Variance,eta)tf noon " 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 Orout O Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) pi3lfesidential Water Supply(sutgte) O Sand Cement Grotit- ., lly Clay QlndustriaXommercial ❑Residential Water Supply(shared) ZeConcrete Grout n ❑ Drill Cuttings Ofai tion ❑ Specialty Grout J t r HP4 ❑Gravel Non-lVater Supply Well: ❑Bentonite)ShiRy,. ❑Other(explain under 7g) ❑Monitoring ❑Recovery I 1`'• i? , Injection Well: 711 For each material sel iftd-abovtyaproaide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation C 1 oncR�'TC ` 3 t440-�5 ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑StonmvaterDrainage ac& U'a:l L __ ❑Etperintental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) OTracer ❑Geothermal(HeatinglCooling Return ❑Other(explain raider 7g) P cS \GlNav `�P`o E �L wry aaae tl it 4.Date well(s)abandoned: v ' So.Well location: p1 ��ar+:�1 L> C o�e►•�Pt�t V: IlecL �:{b.Cu.,-ad -T(Ae�t✓40 P� L :4-1,. i')_rv+�s Facility/Owner Name Facility IDrr(ifappgcable) 8.Certification: n i 9,4 0 �� W S S A w�yy !-�W bt , u� C' C, r>>ar� S 21_�l Physical Address,City,and Zip n f Signatur of Certified Well Contractor or Well Owner Date A.$k O 'J S 13 Q i I By signing this form, I hereby certify that the well(s)was(were)abandoned in County Parcel Identification No.(PiN) accordance wilt I SA NCAC 02C.0100 or 2C.0200 Well Construction Standards and dwi a copy of this record has been provided to the well owner. 5b.Latitude and longitude in degrees/ntittutes/secouds or decimal degrees: (ifwall field one Iau)ong is sufficient) 9.Site diagram or additional well details: Y r 5 O S �V You may use the back of this page,to provide additional Kell site details or well 1 abandonment details. You may also attach additional pages if necessary. CONSTRUCTION DETAILS OF WELL(Si BEL\G ABANDONED §UB\fITTAL INSTRUCTION Attach well constncrionrecord(s)ifarnilable.Formulliplehjecrionornon-aamrsupplywells ONL}'xiNt the saute rottrinatrmdebarularment,}nu cm,nrbntit care form. 10a. For r11F Wells: Submit this fort within 30 days of completion of well 6a.Weil ID#: abandonment to the following: Division of Water Resources,Information Processiug Unit, 61).Total well depth: (ft.) 1617,nail 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 wl el abandonment to the follmviing: 6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program, 1636 ilfail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): (ft.) 10c.For Water Sunnly&Infection Wells: in addition to sending the fort 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.bier casing/tubing length(if known): (ft.) abandoned. 6g.Screen length(if known): (ft.) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 Ma C�' LL Ali BAL\DON-VIENT L�LCQIIR North Carolina Depantrient orEavironment and Natural Resources-Divisionof We,=Quality WELL CONTR-ACfOR CERTIFICA110N WELL RACTOR 5. WELLDE'IAIIS' 3-Vf ft. Diameter.- 31. e il 1 Na me b,Water Level(Below Me)&Irrig Point): ft. mm.1ring point it- ft.above:and surface. tauContractor STRX-ET ADDRESS 4 It-j 4�0 el Tjft-.j"I)A ?& 6. CASING! Length Diameter L a.C 11 tune in. -r Depth Cit.,x T 0%.n Slaw Of Z;p C,)je b.Casing Re-moved Phone number DISLNFECTION-16 O&Z 0A mi ,le: 2.WELL INFORNIATION: (Amount of 651-05%calc=11 hypoublorite zed) SITE WELL ID ft(if applicable)_ I B. .. SEALING MATERIAL: STATE WELL PERMIT 4(if applicable, Nozir Cement Sand Cenuta Cement I'D Cement__ COUNTY WELL PERMIT#(if applicable)_ Water----- Water DWQ or OTHER PERMIT 9.'if applicable) Heritunite WELL USE(Check applicable use)! ❑ MoniWrinii amn e.-Clial Bitntonite lb. �J Municipat/Public '", Indulifial/Commemlial It,t\iricultural Typi:ElSlurry [:]Pellets SE 024P 2 gal. El Recover), [] Injection. ❑ irrigation Other('list use) Type mal6ii.,13-0 Ar 3.WELL LOC.kTION. Amount COVNV&AblOL'A_?RANGLENAM13 �F jNEAiU7ST TO'NN 9, EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL: 4* (Streevkoad Name,Number,Comimmity,Subdivision,L-3t No., Zip Cod:) TOPOGRAPHIC i LAND SETTING: CIElope DValley CFlat CIRIdge[l0ther ('Check appropriate setting) Ii 10. W ELL DIAGRAM D,ii,.%a detailed sketch of the well on the back of this FMay be in degrees, showing total depth,depth and diameter of screens(if any)remainingimnutes,seconds,or in ain the well,gravel intervals hl interval,inteals of casing perforations,and depths an dicbrial format I . . id, LGNGITUDE types crfm rnatefia!s used. 7 Lj Latitudeilongitude source: ,40m;W 0Topu&raphicrnap 11. DATE. WELLABANDONED d! 'Locaoicin of vntfl must he shorn on a USGS to'po map and I anochcd iotkis f*brm ifilor using GPS.) I DO HEREBY CERTIn'THAVINIS WELL WAS ABANDONED IN ACCORDANCE - 4m.FACILITY-Thu iiwm of the business where the wall is located.Complete 4a and4b. WITH I SANCAC 2C,WELL CONSTRI.1c.-noN STANDARDS,AND THAT y,eCPY 0-6 (If a residential well,skip 4&,winplote 4b,well owner 6formfion only) THIS REC RD HA15 3EEN PROVIDED TOTHE WELL OWNER. FACILITY ID,#(ifapplicable) r'Amr;'OF FACILITY_ 7,,Tq=T.- _ERTIFiTD PIT DATE STREET A7DDRESS ' City of Town State• qG THY WELL D;�fi Zip e SIGNATWX OF PRiVATE.WELOWNERA11ANT169F17 (The private well owner must be an individual who Dcrscyrially abandons his/her residential well 4b,CONTACT PERSON in ac:ordrince ith 15A NCAC 2C.G I I-.;.) NAME U-11; PRINTED NAME OF PERSON ABANDONINGTHE WMA, r ST RE-7 A1)1'1Ri_S$ 4 tk 4 44 91 6e o-L4 Submit copy lothe ocher and,the original to the Dhislen of Water Quality within 30 days. Form G W.31) Attn:InforTnatiouNtanagement,1617 Mali Service Center—Raleigh,NC 27699L1617, Phone No.(9I9)733-70I5gxtS68. Rev.5!06 Li tZ A7zz'R 4)l/f7V F 2t yz 4f0n�c244 �✓zr� �W?lI ST,u�ia- t,)rOP"e�z Le ct�` f'ilL �is' TJ ELT 1-5 P 30 t1 zz� .� 7'p ;,j tAJA ram, �j fZz wgs :f�o�;�,,�� C) 2 FYLlEd F- gom po77� r-r OD ri 3 .1c: ,T 7'IA E 466 7' F Lr E- 7 k�p, ,5 yp -90 o Q ?,-5 rr e- 4 A E 7-f