Moore_Well Abandonment_20221208

WELL ABANDONMENT RECORD For Internal Use OIJLY:
This form can be used for single or multiple wells
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lawrence D. Opper 7a.Number of well.being abandoned: 11 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water 'supply wells ONLY with the same
construction/abandonment,you can submit one form.
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,Variance,etc.)ifknown 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 Z Bentonite Chips or Pellets
❑Geothermal (Heating/Cooling Supply) ❑Residential Water SuPP1Y(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel (AFC 2�ZL
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain undert-7gj
Monitoring DRecovery
7f.For each material selected above,provide amount of mkltcrials'used� fir`'C':,
Injection Well: vl°> ! rL
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips:2°MW:1.6lbs/ft(24-56lbslwell)
❑Aquifer Storage and Recovery ❑Salinity Barrier Bentonite chips:4^MW:6.3lbs/ft 100-157Ibs/we11)
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Filled/hydrated from bottom-up. Capped with concrete.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
MW-1 (2"x15'), MW-1 D(2"x35`),MW-2(2"x15'), MW-3(2"x15')
4.Date well(s)abandoned: 10/14/2022 MW-4(4"x10.6%MW-5(2"x15'),MW-6(2"x15%OW-1/MW-1 (4"x2l')
5a.Well location: OW-3/MW-3 (4"x16'), AS-1 (2"x25')
Country Cubbard NClncident#2902
Facility/Owner Name Facility ID#(if applicable) $•Certification: 7
4915 US Hwy 15/501, Carthage Lawrence Opper� 11/6/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Moore 11
By signing this form, I hereby certi6y that the well(s)was (were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A 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 ladlong is sufficient) 9.Site diagram or additional well details:
35.3159687 79.4149587 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 j
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same constructionlabandonment,you can submit one farm. 10a. For All Wells: Submit thisi;form within 30 days of completion of well
6a.Well lD#: Seb 7g abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 10.6-35 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
well dia: 2-4 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following: j,
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approx 8-10 ft Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
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10c.For Water Supply&Injection 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
6E Inner casing/tubing length(if known): (ft.) where abandoned.
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6g.Screen length(if known): 5-15 (ft.) `
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Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013