Catawba_Well Abandonment_20241115

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Alfred Ki esl I ng Jr 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
3266-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
B & K Well Drilling Inc FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorine
q�/rt 7c.Type of disinfectant used:_
2.Well Construction Permit#:(Air II Pr T i 1 a," -d a.
List all applicable well construction permits(i.e. UC.County,State. Variance,etc.)if known /� eT lJ Lin��7
7d.Amount of disinfectant used:
3.Well use(check well use): •
Water Supply Well: 7e.Sealing materials used(check all that apply):�
Lr❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout 1Sentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ••Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) /—Croncretc Grout U Drill Cuttings
0 Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring D Recovery
Injection Well: 7f.For each material selected above,provide/ amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation � S [ '�4v4'
❑Aquifer Storage and Recovery ❑Salinity Barrier �f1� �p
❑Aquifer Test ❑Storrnwater Drainage R i �i'^e
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ]Tracer 7g.Provide a brief description oft
e abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) p CJrn ) 4-- (�F v(G� �e(
pc I) Pr coelc_r-oltr
4.Date well(s)abandoned: /a///ol 7 -
5a.Well location: r
Facility/Owner Name L,4 rK,1.. _( V a y{M,.. Facility IDa(if applicable) 8.Ce 'fication:
a2 g1;3-3 4A-La 4'.be ?1 et tAT Rol -.11431‘4L b fe)—a'—°Z
Physical� Address,City,and Zip Signature of Trifled Well C tractor or Well Dare
l�A i-c-e'� bat 36 c-5-?6-2,66 Si?By signing this form, I hereby certify at the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A 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 Lit/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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well Mt: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
Q 10b. For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: Pi? (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: /al (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) IOc.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 Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY!
1.Well Contractor Information: WELL ABANDONMENT DETAILS
`iJ et•aC" c.c�( ( r\ 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
C�� wells abandoned: i
/
r" ')4 7b.Approximate volume of water remaining in w•ell(s): 7 02 d (gal.)
NC Well Contractor Certification Number
u f/_ I FOR WATER SUPPLY WELLS ONLY:
1�I -11i � tt i!VICeS
CIn1a:;s-e- y hvc, (
Company Name7c.Type of disinfectant used: /
�
2.Well Construction Permit#: lb-2 t)1 d� 14 Jtt 7 o✓Z
List all applicable ncll construction permits(i.e.UiC,County,State,Variance,eta)if!mann 7d.Amount of disinfectant used: ) Z
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public Wkeat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) )Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑IndustriallCommercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 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 4 y d —
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stom,watcr Drainage
-
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer f/ e 'O kde /
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
-CI'If p.�i r ,5t�(C--F :04
4.Date well(s)abandoned: 1(43I l 1
4.
5a.Well location: t •
i
L,.e ft c,t ifi Certc NOV V j ih w r...
Facility/Owner Name Facility iDil(if applicable) 8. 2024
(t)) 42rz4 { Pt Full; hk ' %i -, • 3i' r�4
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner...-;,,,, Date -
Q�-t3. �.. By signing this form, 1 hereby ceriifi'that the well(s) was (were)abandoned in
County Parcel Identification No.(PiN) accordance with I5A ACAC 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:
(amen field,one IaVlong is sufficient) 9.Site diagram or additional well details:
Gl f 33GYou may usc the back of this page to provide additional well site details or well
35 'j c,l' Z O N LJ W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well commit tionrerwd(s)ifavailahle. For multiple injection ov non-water anpplywells
ONLY nit);the same construction/abandonment,)on can submit one form 10a. For All Wells Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID#:
Division of Water Resources,Information Processing Unit,
1617 Mall Service Center,Raleigh,NC 27699-1617
6b.Total well depth: � S (ft.)
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: Z 1 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
lid.Water level below ground surface: 1 S (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): /V/.4 (ft.) 10c.For Water Supply&Infection 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
M.Inner casing/tubing length(if known): N/j!} (ft.) abandoned.
6g.Screen length(if known): NM_
/ Q (ft.)
I'm in GW-30 North Carolina Department of Environmental Quality-Div ision of Water Resources Revised 2-22-2016