Catawba_Well Abandonment_20240910

WELL ABANDONMENT RECORD For internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
// C_i J In- ��'j � 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
r FOR WATER SUPPLY WELLS ONLY:
Company Name t
C� C
7c.Type of disinfectant used: �' le"t .ti2
2.Well Construction Permit#: t 10
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List all applicable wrll construction permirs(i.e.UC.County,State,Variance•etc.)it knonn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 77e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 61'iVeat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) CVAKesidential Water Supply(single) O Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material lected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier --7
❑Aquifer Test ❑Stonuwater Drainage
[]Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ` r
❑Geothermal(HeminglCooling Return) ❑Other(explain under 7 )
rr�L C''d9 tY'y7
4.Date well(s)abandoned: ( T '
5a.Well to tion: '
FacilityiOw ncr Name Facility 1134(if applicable) 8.CertiBc a:
4-�yS anP�� 4kLi 2-Ul
ci
Physical Address,City,and Zip 1 + Signature of Certified Well Contractor or Well Owner Data
��F (�3 " By signing this form, 1 hereby certify that the wells) it-as(were)abandoned in
County Parcel identification No.(PIN) accordance with 1 SA 1VCAC 112C.0100 or 2C.0100 Well Contraction Standards
and that a cony of this record has been provided to the hell owner.
Sb.Latitude and Longitude in degreedminutes/seconds or decimal degrees:
(ifwell field,one IaVlong is _ � , G sufficient) 9.Site diagram or additional well details:
35 t15^ 13 N ��)G W 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
dttarb treliconstrrtction recard(.r)ifm ailable. For multiple injection ornmr-sister supply xells
ONLY kith the same cunstruction/abandarnnenl, ou can submit one form
��,,r�� � 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• —aq abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: —� (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
v 10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: i a (in.) above,also submit one copy of this form within 30 days of completion of well
'7 abandonment to the following:
6d.Water level below ground surface: ! (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection 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
611 Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Porn OW-30 North Carolina Department of Enviramnental Quality-Division of Water Resources Revised 2-22-2016