Granville_Well Abandonment_20220607

WELL ABANDONMENT RECORD For Internal Use ONLY:
This forth can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lawrence D. Opper 7a.Number of wells being abandon 6d:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wv/ls ONLY with the same
construction/ahandonmeni,You can submit'one form.
NC 3322-A
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
Regional Probing Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicahle well construction permits(i.e.County,State,Variance,etc.)iflmoNm 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 O 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)
O Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips:1.6 Ibs/ft(27 Ibs)
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of tFie abandonment procedure:
oceotnennal(closed Loop) ❑Tracer Filled/hydrated from bottom-up. Capped with concrete.
❑Geothermal(Heating/Cooling Return) OOther(explain under 7g)
4.Date well(s)abandoned:
5a.Well location: _. JUN 0.7 ,2022
Piedmont Property Incident#10433
8..Certification: I ofitdiBvltZn Pri��ir,q Uni
Facility/Owner Name "" FacilityID#(ifapplicabie) t� /P/rt
Oxford Loop Rd. & US Hwy 15, Oxford Lawrence Opper� 5/13/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Granville By signing this form, I hereby certify 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:
lifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.335602 ' 78.593306 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 constriction ret-md(s)if availahle. For multiple injection or non-usher supply
wells OV1,Y with the same consimction/ahandonrnent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: Triangle Well abandonment to the following:
Division of Water Quality;Information Processing Unit,
6b.Total well depth: 17 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the forni to the address in 10a
Well dia: 2 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
approx 9 Division of Water Quality;Un,'derground Injection Control Program,
6d.Water.levcl below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Sunoly&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
6f.Inner casin Lubin length if known): 7 ft. where abandoned. i
casing)(tubing g ( ) _ _( ) I
6g.Screen length(if known): 10
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013