Gaston_Well Abandonment_20241101

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WELL ABANDONMENT RECORD For Internal Use ONLY: ,
1.NIXe
llntractor Information: (` WELL ABANDONMENT DETAILS
/ Jj/e, 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Mime(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
3 7 �j�r C wells abandoned:
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NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): /5 (gal.)
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f
Lea Ws el(4- Aet0 Dc . FOR WATER SUPPLY WELLS ONLY:
Company Name1Bleach
7a Type of disinfectant used:
2.Well Construction Permit#: 'Li •
/ ^/Vi;�//D n
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: • 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MM/u'nicipal/Public 0 Neat Cement Grout Y . 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) I sidential Water Supply(single) 0 Sand Cement Grout i 0 Dry Clay
Dlndustrial/Commercial ❑Residential Water Supply(shared) l 'h�ncrete Grout ❑Drill Cuttings
0Irrigation 0 Specialty Grout 0 Gravel .
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 677Y �S
❑Aquifer Storage and Recovery OSalinity Barrier /
❑AquiferTest l7StormwaterDrainage Lu�4
❑Experimental Technology l7Subsidence Control ;, NOV
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer I !r<3,;,�ji. .� �rr.� f- ! y
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g) C /®�'� e�/ Lt%i 7� (?/`>LfG: /-�
4.Date well(s)abandoned: [O 4Z2� C,i f e/ 1!r D/7 i,/A 4
5a.Well location: ! / /�i ( ! // //Q
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•�aea•
(3r00a0l S'Ore4fee Wail rm4dre . .
Facility/Owner Name •. Facility DX/(if applicable) 8.Certification:
I Bello4/fve./1 14//7 A/C o?fP420 ;0 , /oh/
Physical Address,City,and Zip Signature of Frfled Well Contractor or Well Owner Date
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CaS-64 By 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: j
(if well field,one lat/long 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)favailable.For,multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: • abandonment to the following:
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1 Division of Water Resources,Information Processing Unit,
6b.Total well depth: / 7 (ft.) Division
Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 1t (in.) above,also submit one copy of this form within 30 days of completion of well
.. _. abandonment to the following:
Division of Water Resources,Underground n derground Injection Control Program,,
6d.Water level below ground surface: / (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Al (ft,) 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 abandonmentcounty:health of thecounty to the o hea department where
•6f.Inner casing/tubing length(if known): (ft)
abandoned.
6g.Screen length(if known): (ft)