Alamance_Well Abandonment_20220815

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 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-Nancr supply url/s ONLY with the same
conetnrction/ahandonment,you can submit oneform.
NC 3322-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
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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(Le.(btmt,SS I ariawe,etc.)ij'knotua 7d.Amount of disinfectant used:
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3.Well use(check well us a,,., E_e D
Water Su ly Well: , � 7e.Sealing materials used(check all that apply):
❑Agricultural AUG ! �h+RfnrlTpal/Public ❑Neat Cement Grout El Bentonite Chips or Pellets
❑Geothermal(Heating/CI o in p.o pr�i@j pter Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑industrial/Commercial (A?,Jidential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
oMonitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite.5 Ibs/ft(5-12lbs/well)
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
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❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the Abandonment procedure:
❑Geothermal(Closed hoop) ❑TraCCr Removed well and backfilled boring with hydrated bentonite.Capped with concrete where applicable.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
RI-GW-1 (13'), RI-GW-2 DPf(23'), RI-GW-4 DPT(24')
4.Date well(s)abandoned: 6/23/2022-6/24/2022 RI-GW-5(13'), RI-GW-6(9'), RI-GW-7(19% RI-GW-8(16')
5a.Well location:
Former Tarheel Army Missile Plant
Facility/Owner Name Facility lD9(ifapplicable) 8.Certification:
204 N. Graham Hopedale Road, Burlington Lawrence Opper 7/12/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Alamance By signing this form, 1 hereby certify that the well(s)was (were)abandoned in
County Parcel Identification No.(PIN) accordance will;15A NCAC 02C.0100 or 2C.0200 Well Constnuction Standards
and that a copy of this record has been provided to fire 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:
36.0981223 79.4076854 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)ff available. For multiple injectiod or non-water supply
wells ONLY with the same construction/abandonment,you can submit one jn.m. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
See 7g abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 9-24 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Infection Wells: In addition to sending the form to the address in 10a
Well dla: 1 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter. (in.) abandonment to the following:
BpprOX 8-12 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (f1J 1636 Mail Service Center,Raleigh,NC 27699-1636
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10c.For Water Saw*&Infection 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
where abandoned.
6f.Inner casing/tubing length(if known): (ft-)
6g.Screen length(if known): 4-10
g
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Form OW-30 North Carolina Department of Environment and Natural Resources—Division of Water Qriality Revised March 2013