Wake_Well Abandonment_20221031

WELL ABANDONMENT RECORD Forlaremd Uae ONLY.
This form can be used for single or multiple wells OCT 3 1. 2022
1.Well Contractor Information: WELL ABANDONMENT DETAHS IINOrT,14ion Pf^-3"drg tdrdl
Lawrence D. Opper 7a.Number of wells being abandoned: 1 `wailloG
Well Contractor Name(or well owner cranially abandoning well on his/her property) For multiple injection or non-wafer supply wells ONLY wid the same
3322-A cmetow mIabaMomeent.you can submit oneform.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
Regional Probing Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permit(i.e.Count',Shaa,Ya kuusc.ere.)If known
7d Amount of disinfectant used:
3.Well out(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
OAgricultural ❑MunicipaVPublic ❑ Neat Cement Grout a Bemmnite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) O Sand Cement Grout ❑ Dry Clay
Olodustrial/Commercial ❑Residential Water Supply(shared) O Concrete Grout ❑ Drill Cuttings
Dinfigation ❑ Specialty Grout ❑ Gravel
Noe-Water Supply Well: ❑Bemmnite Slurry ❑Other(explain under 7g)
OMonitoring ORecovery
fajeetion Well: 7f.For each material selected above,pion,ide amount of materials used:
❑Aquifer Recharge OGroundwater Remediation 24lbs bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
OAquifer Test OStormwitter Drainage
OExperimental Technology OSubsidence Control 7g,Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer Filled/hydrated from bottom-up.Capped with T of concrete.
OCaothermal(Heating/Cooling Return) Other(explain under 7 )
Geoprobe 5410-Truck utilized.
4.Date well(s)abandoned: 10/8/2022
52.Well location:
Ameriking Food Mart
Facility/Owner Name Facility ID#(if applicable) &Certification:
1709 Lake Wheeler Road, Raleigh Lawrence Opper 10/16/2022
Physical Address,City,and Zip Signature of Candied Well Contractor or Well Owmr Dare
Wake 0 signing this oral 1 here tern that the welts was
Y 8n g f by fY () (ware) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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 IaMong is sti fickm) 9.Site diagram or additional well details:
35.76004286 78.6610051 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
Armch well construction retard(r)if available. Fnr multiple igecnon or non-wirer.supply
wefk ONLY with the some con ervaum.band nment,you c.n submit oneform. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 15 (fL) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: well I.D.=2.0(in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
a cox. 10 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: pp 00 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply& Iniection 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): 2 Ih.) where abandoned.
6g.Screen length(if known): 10 (ft)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Rmsed March 2013