Alamance_Well Abandonment_20240325

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WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
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Lawrence D. Opper 7
PP 7a.Number of wells being abandoned:
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
construction/abandonment,you can submit one form.
3322-A
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 7c.Type of disinfectant used: 1
2.Well Construction Permit#: ;'
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
1
3.Well use(check well use):
i
Water Supply Well: 7e.Sealing materials used(checkiall that apply):
0 Agricultural ❑Municipal/Public 0 Neat Cement Grout ' . ' 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial :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)
IZiMonitoring ❑Recovery
Injection Well: 7f•For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation bentonite chips:1.6 lbs/ft(32-75 Ibs/i ell)
❑Aquifer Storage and Recovery ❑Salinity Barrier 1
❑Aquifer Test ❑Stormwater Drainage '
❑Experimental Technology ❑Subsidence Control '
7g.Provide a brief description oEthe abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Filled/hydrated from bottom-up. Capped with concrete.
❑Geothermal(Heating/Cooling Retum) 0 Other(explain under 7g)
MW-1(25')MW-1 D(47')MW-2(20MW-3(20')MW-4(20')MW-5(20')MW-6(20')
4.Date well(s)abandoned: 2/26/2026 !
5a.Well location:
Bradsher Mini Mart NCDEQ Incident#24434 Facility/Owner Name Facility ID# _(if applicable) 8•Certification: IF ,
5401 NC Hwy 119 North, Burlington Lawrence •pperie',7-.o - 3/15/2023 .
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Alamance By signing this form, I hereby certifi,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 ben 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:
36.224465 79.298431 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 construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: Monitoring Wells-see 7g abandonment to the following: 1
T ,r �^ Division of Water Qualiity,Information Processing Unit,
20-47 r-- "":" !i i 'a 1617 Mail Service Center Raleigh,NC 27699-1617
6b.Total well depth: (ft.) r I.*--7 t'�4"i.:. it r-ii s) 1,
g '
'-x 2 A 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: well I.D.=2.0(in.) Mt t 2 024 above,also submit one copy of this form within 30 days of completion of well
1 1 abandonment to the following:
lniti.iT 1z i1{i7r p ,x-24=:r5 Liga i
6d.Water level below ground surface 8 D ',3'< Division of Water Quality,Underground Injection Control Program,
1636 Mail Service 'C inter,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 Ito the county health department of the county
where abandoned. !
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013