Onslow_Well Abandonment_

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells , -7
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1.Well Contractor Information: ;" vWELL ABANDONMENT DETAIIsS.
Lawrence D. Opper JAN p 9 2023 7a.Number of wells being abandoned: 7
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
In„„�,.��:,^n �r;•..�;yq.;n (holtstruction/abandonment,you can submit oneform.
NC 3322-A �t;e l�;�'�i
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number j
Regional Probing Services FOR WATER SUPPLY WELLS ONLY:
Company Name 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: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips: 35lbs
❑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 Temporary Wells: Removed well and backfilled with hydrated bentonite.
❑Geothermal(Heating/Cooling Return) []Other(explain under 7g)
TW-1 (5'),TW-2(6),TW-3(6'),TW4(6'),TW-5(6),TW-6(6')TW-7(6')
4.Date well(s)abandoned: 12/14/2022
5a.Well location:
Coastal Cleaners DSCA 670012
Facility/Owner Name Facility IDN(if applicable) $•Certification:
2155 Le•eune Blvd. Jacksonville Lawrence Opp
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Onslow By signing this form, I hereby certify that the well(s)was (here) 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 lat/long is sufficient) 9.Site diagram or additional well details:
34.74088368 77.36334544 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 records)if available. For multiple injection or non-water supply
wells ONLY with the same constructionlabandonment,you can submit oneform. 10a. For All Wells: Submit this'form within 30 days of completion of well
6a.well ID#: TW-1 through TW-7 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth 5-6 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
well dia: 1 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
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6d.Water level below ground surface: approX 4 (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Sunaly&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): 0 (ft.) where abandoned.
6g.Screen length(if known): 5 (ft.)
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Form GW-30 North Carolina Department of Enviromnent and Natural Resources-Division of Water Quality Revised March 2013
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