Catawba_Well Abandonment_20240918

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Informati n: WELL ABANDONMENT DETAILS
" r P ,1 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
LI wells abandoned:
NC Well Connector fication Number 7b.Approximate volume of water remaining in well(s): 4 A-(gal.)
Q FOR WATER SUPPLY WELLS ONLY:Company Namc 7c.Type of disinfectant used: Tt TG/
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: 0 Z
3.Well use(check well use):.
Water Supply Well: 7e being materials used(check all that apply):
❑Agricultural ❑ l/P Mumicipaublic Neat Cement Grout ❑ Bentonite Chips or Pellets
Dermal(Heating(Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
Prial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
01rrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Moritorirg 0-Recovery
Injection Well: 7£For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.P vide a brief description of the aband nment procedure:
❑Geothermal(Closed Loop) ❑Tracer �/� �j/J .,�/��,
❑Geothermal(Heating/CoolingReturn) ❑Crther(explain under 7 ) r 1 l J C v l LJ /r/ "1 �O n P
4.Date well(s)abandoned:
Sa.Well locaa�t:_ UZ4
Facility/Owner Name Ir",:`;;.?.'a:l;f'� �,t;•^.;.r«C;�,a >.
Facility ID#(((iifffapplicable) 8.Certification:
Physi City,and Z' Signature of Certified Well Contractor or Weft Owner Date
B signing this orm, I hereby certi that the wells was were abandoned in
Y Sn�g f Y f3' () (were)
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/iong is sufficient) 9.Site diagram or additional well details:
N 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. ZANDONED SUBMl`fTAL]INSTRUCTIONS
Attach well construction record(s)tfavoilable.For multiple injection ornon-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
f 10a. For All Wells: Submit this form within 30 days of completion of well
63.Well ID#: /U ,el e abandonment to the following:
a
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (fL) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in I Oa
6c.Borehole diameter: (iu) above,also submit one copy of this form within 30 days of completion of well
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): (g,) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this foam within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(ifknown): ®/- C A) abandoned.
I -
6g.Screen length(if known): D n e A)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resouices Revised 2-22-2016

LU),'d C, 2 lv�lt t�l �l :r_ t, Ca
WELL ABANDONMENT RECORD For Internal Use ONLY: r,+
1.Well Contractor Information: WELL ABANDONMENT DETAILS
11
Alfred Kieslin Jr
9 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
3266-A
NC Well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): O_(gal.)
B & K Well Drilling Inc FOR WATER SUPPLY WELLS ONLY:
Company Name Gh IOri n e
�l 7c.Type of disinfectant used: .
2.Well Construction Permit#: .2yO,?1 q i
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: `RY�/'� /�o QLY21,2 r��
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout mite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) FResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial El Residential Water Supply(shared) Gl.426n—cretc 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 selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 1L 13 A 5 � ( �`(zci
❑Aquifer Storage and Recovery ❑Salinity Barrier v ��
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description'of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer / /
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
� [�1�✓'"-�+l ��t t�''�ill"'k
4.Date well(s)abandoned: Z+'S ` `"'�• '' ,'� �'r
5a.Well location: ' r S E N
Q.r...a ��m �+ �2t(�N>7n Ififri:f',ft;f i }art.•^:3+11G; 11is
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
Physical Address,City,and Zip StWaRuif eAlfied Well Co ctor or Well O e V Date
gy signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient)
9.Site diagram or additional well details:
N 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
Attach well construction record(s)iifavailable. For multiple injection ornon-watersupply ivells
ONLY with the same construction/abandonment,you can submit oneform.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For lniection 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
abandonment to the following:
6d.Water level below ground surface: ! (ft.) Division of Water Resour Ies,Underground injection Control Program,
1636 Mail Servile Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g,) 106.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 i county health department of the county where
6E Inner 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 Rose Ire,cs Revised 2-22-2016