Lee_Well Abandonment_20220919

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lawrence D. O er i
PP 7a.Number of wells being abandoned; 16
Well Contractor Name(or well owner personally abandoning well on his/her roperty For multiple injection or non-wafer supply wells ONLY with the same
�,e• "p consiructionlabandonment,you can submit one form.
NC 3322-A
7b.Approximate volume of water remaining in well(s): 0 (gal.)
NC Well Contractor Certification Number _ G 2022
Regional Probing Services SLF L`I FOR WATER SUPPLY WELLS ONLY:
Company Name ^.1 �`''"i
ltt` `���r>'� �"' t 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,variance,etc)if known
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 Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ 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: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips: 24-94 lbs/well
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Filled/hydrated from bottom-up. Capped with concrete.Geoprobe 5410truck utilized.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
MW-1R(17'),MW-2(16'),MW-3(171),MW4(17'),MW-6(15'),MW-8(15')
4.Date well(s)abandoned: $/3/2022 MW-9(15'), MW-10(15'),MW-11(15'), MW-13(15'),MW-14(15')
5a.Well location: MW-15(15'),MW-17(15'),MW-19A(20'),DW-2(50')RW-1(4"x15')
Former Scotchman #99
Facility/Owner Name Facility ID#(ifapplicable) g•Certification:
1141 N. Horner Blvd., Sanford Lawrence O er`:m@8/17/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Nell Owner Date
Lee
By signing this form, I hereby cerlify 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:
(ifwell field,one latflong is sufficient) 9.Site diagram or additional well'details:
35.496107 79.1972029 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same constructionlabandonment,you can submit one farm. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: See 7g abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 15-50 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
well dia: 2-4 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter. (in.) abandonment to the following:
6d.Water level below ground surface: 3-5 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Suoaly&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
6E Inner casing/tubing length(if known): (ft.) where abandoned.
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6g.Screen length(if known): (ft.) t
Form G W-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013