Moore_Well Abandonment_20221031

WELL ABANDONMENT RECORD Forintemal Use ONLY t
This form can he used fa single or multiple Wells O C 1 3 1 2022
1.Well Contractor Information: WELL ABANDONMENT DETAILS Il17uf�iti4�2n Pr,;%Vng um
Lawrence D. O r 1 C�A10;3JG
PIS 7s.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/Mr property) For multiple oi,,,uan or non-anrer supply weds ONLY with the same
NC3322-A rorarrucnrutabandonmenr,you can submit me form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining ja well($): 0 (gal.)
Regional Probing Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type ofi isinfectant used:
2.Well Construction Permit N:
U.n all applicable well consructon permus(ce.Caunry,Store, Variance,etc.)rf brawn 7d.Amount of disinfectant used:
3.Well use(check well on):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaMblic ❑Neat Cement Grout m Bentonite Chips or Pellets
OCrcothertnal(Heating/Cooling Supply) ❑Residential Water Supply(single) D Sand Cement Grout ❑ Dry Clay
Olndustrial/Commercial OResiderthal Water Supply(shared) O Concrete Grout ❑ Drill Cuttings
❑Irri tion ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bemmnite Slurry ❑Other(explain under 7g)
®Monitoring DRecovery,
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge OGrouidwater Remediation Bentonite:1.6 lbs/ft(51-88 Ibs/well)
OAquifer Storage and Recovery ❑Salinity Barrier
OAquifer Test ❑Stormwater Drainage
DExperimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
oGenthe mal(Closed Loop) OTracer Filled/hydrated from bottom-up. Capped with concrete.
OGeothermal(Heating/Cooling Return) OOther(explain under 7g)
MINA (55% MW-2(55% MW-3(55'), MW-4(50'), MW-5(52')
4.Date well(s)abandoned: 9/14/2022
5s.Well location:
Fairway Pizza
Facility/Owner Name Facility IIM(ifappliable) &Certification:
4115 NC Hwy 211 W., West End Lawrence Opper -- 9/14/2022
Physical Address,City,and Zip SigrWme ofCceti6ed Well Container or Well Owner Data
Moore B signing this form, I here certify that the wells was y gn g f by fy (/ (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 is degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iatllong is sufficient) 9.Site diagram or additional well details:
35.267187 79.59062 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
bench well construction record(s)f avnilable. pbr mull ple i jectmn or oen-warer supply
wells ONLYwuh the.mme cans rrucaon.bmdonmena you coosubmuooeJarm. 10a. For All Wells: Submit this form within 30 days of completion of well
6s.Well IDq: MW-1,MW-2,"-3.MW<,MW-5 abandonment to the following.
Division of Water Quality,Information Processing Unit,
66.Total well depth: see 7g ID.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: WeII dla: 2 (ia) above,also submit one copy of this form Within 30 days of completion of well
abandonment to the following:
approx 47 Division of Wster Quality,Underground Injection Control Program,
6d.Water level below ground surface IN 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer rasing length(if known): (R) 10c. For Water Supply& Injection Wells: In addition to sending the form to
the For
above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
6L Inner casi ng/lu bi ng Itngth(if known): 1re1 where abandoned.
6g.Screen length(if known): (fL)
Fo.GW-30 North Carolina Depannent of Environment and Natural Resources-Division of Water Quality Revised March 2013