Durham_Well Abandonment_20220718

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILSt
Lawrence D. Opper 7a.Number of wells being abandonled: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-wafer supply wells ONLY with the same
construction/abandonment,you cah submii,one farm.
NC 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:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,{'ariance,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 I El Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 4 ❑Dry Clay
01ndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout f ❑Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g).
OMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer•Recharge ❑GroundwaterRemediation Bentonite 48bS.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Ceothennal(Closed Loop) ❑Tracer Filled/hydrated from bottom-up. pp dov/ iz '�'IFT'Srncrete.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Jill 18 ?n�?
.4.Date,well(s)abandoned: 5/19/20,22
5a.Well location: tp, r �• r Ursa
.Bilboa-Food Mart Incident#22398 �' �;_:;�? ,°ai,�?;1 pF.-tir^t?•` �j T
Facllitv!OwnerName Facility IDS#(if applicable) 8•Certification:
3639 Angier Avenue, Durham , Lawrence Opper..-SF­ 6/15/2021 .
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Durham By signing this form, I hereby cent �That the well(s)was(were)abandoned in
County Parcel Identification No.(PIN), accordance with 1 SA NCAC 02C.0100 or 2C.0200 II'ell Construction Standards
and that a copy of this record has been provided to file well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ; i
(if well field,one latllong is sufficient) 9.Site diagram or additional well details:
35.956435 78.852709 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
Minch well construction record(s)if available. For multiple injection or non-sinter 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#• MW-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6h.Total well depth: 30 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniecfion Wells: hi addition to sending the forin to the address in IOa
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 6 Division of Water Quality,Underground Injection Control Program,
6d.Water level below.ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
I i
IOc.For Waiter Supply&Iniecfion Wells: In addition to sending the form to
6e:Outer casing length(if known): (ft.) the address(es) above, also submit Lone copy of this form within 30 days of
completion of well abandonment to!the county health department of the county.
'
6L Inner casing/tubing length(if known): (ft.) where abandoned.
i
1
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013