New Hanover_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 DETAWS
Lawrence D. Opper 7a.Number.of wells being abandoned., 2
Well Contractor Name(or well owner personally abandoning well on his/her property) • For multiple injection or non-Hater! supply hells ONLY with the same
conrtnrctionlabandonment,you can submit one fonn.
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#: WM0801188
List all applicahle well construction pt'rmits(i.e.County,State,Variance,etc.)ifknoun 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 El 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
❑lrrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7C For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite:Approx 18 Ibs/per well.
❑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 2 Geoprobe DPT groundwater sampling locations.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Removed Geo robe DPT sam ler and backfilledl nd�A w th,. t' be bite.
4.Date well(s)abandoned: 4/21/2022
JUL I
5a.Well location:
Lee Van Ormer 11AfM- IOil
8.Certification: ''� '" 1i���tP'U�e lh;3UNIF
Facility/Owner Name Facility ID#(if applicable) 17„r' y 1 i I � '
1602 Burnett Blvd., Wilmington Lawrence Opperp: a 5/13/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
i
New Hanover R05417-016-002-000 By signing this form, I hereby ceithl that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Constnuction 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:
34.215177 77.94445 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 trel1 consinrction record(s)if available. For multiple injection or non-water supply .
welly OV,Ywith the same conrtniction/abandonment,you can submit onejinni. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: See 7g abandonment to the follmving:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 12 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
Gc.Borehole diameter: (in.) abandonment to the following:
j
a 8 Division of Water Quality,Underground Injection Control Program,
Gd.Water level below ground surface. pprox. (ft.) 1636 Mail ServicelCenter,Raleigh,NC 27699-1636
10c.For Water Suoaly&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also subini( one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned.
6f.Inner casing/tubing length(if known): (ft.)
I
6g.Screen length(if known): 4 l
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
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