Richmond_Well Abandonment_20221031

+ 4!6e E 1 1V rgqo e`1. ,
gq WELL ABANDONMENT RECORD For Internal Use ONLY: OCT 3 20LL
This form can be used for single or multiple wells
I.Well Contractor Information: WELL ABANDONMENT DETAILS In;3--5-Zw n rCc..rG.Sn:
Lawrence D. Opper 7a.Number of wells being abandoned: 5
Dr.4'Q/30G
Well Contractor Name(or well owner personally abandoning well an his/her pmperry) For muhiple injection or ant-water supply wells ONLY with the same
maserecaonlabandonmem,yvu 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:
2.Well Construction Permit#:
List all applicable well construction pertain(.e.County,State,Variance,etc)tf.bmwn 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 0 Bentonite Chips or Pellets
DGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) O Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial DResidential Water Supply(shared) O Concrete Grout ❑ Drill Cuttings
011-rigation ❑ Specialty Grout ❑ Gravel '
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
[]Aquifer Recharge OGroundwater Remediation Bentonite 1.61bs/ft (24-75)lbsl well)
DAquifer Storage and Recovery OSalinity Barrier
DAquifer Test OStormeater Drainage
DExperimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
DGeothennal(Closed Loop) DTracer MW-1(2l'),MW-2(20'),MW-3R(16),MW-0R(15'),MW-5D(47')
❑Geothermal(Healing/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 9/14/2022
So.Well location: filled/hydrated from bottom-up:Capped with l'of concrete.
Hamlet Starflight Store#273 Incident#29013
Facility/Owner Name Facility ION(if applicable) $-Certification:
327 E. Hamlet Avenue, Hamlet Lawrence Opp rt==1=-z--m-- 9/14/2022
Physical Address,City,and Zip Siguahne of Certified Well Contractor or Well Owner Date
Richmond By signing this form, I hereby certify chat the ivell(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:
(if well field,one IatAong is sufficient) 9.Site diagram or additional well di
34.88214 79.691450 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 mailable. ror multiple injection or non-water supply
wetIsOA'LI'withthesamecomiruction'abandonmmi,youcansubmironeform. IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: raw-+.raw-z"MAP,nnwR.M-50 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 15-47 (fit) 1617 Mail Service Center,Raleigh,NC 27699-1617
1.
I Ob.For Infection Wells: In addition!to sending the form to the address in ]Oa
well I.D.=2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
i
approx. 8 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
1
10c.For Water Supply&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (Ft) the address(es) above, also submitione copy of this form within 30 days of
completion of well abandonment loathe county health department of the county
6E Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): 5-15 (ft.)
Fawn GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013