Rockingham_Well Abandonment_20221208

WELL ABANDONMENT RECORD For Internal Use ONLY:
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 wells being abandoned: 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#: ;~� ^L'L j V
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
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3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that jp1?Jy)A-,U2_n ar.Y, -i,;!ng kjrC is
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 2 Bentonfte!Uhiti oRPellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RIMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRernediation Bentonite 1.6 Ibs/ft(99 Ibs)
❑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 Filled/hydrated from bottom-up. Capped with concrete.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
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4.Date well(s)abandoned: 11/1/2022
5a.Well location: Geoprobe 5410 Truck-mounted rig utilized.
Kuntry Korner
Facility/Owner Name Facility ID#(if applicable) S.Certification:
1075 Bald Hill Loop, Madison Lawrence Opperl�� 11/17/2022
Physical Address,City,and Zip Signature of Certified Well Contractor on Well Owner Date
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Rockingham By signing this form, I hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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:
(ifwell field,one Iat/long is sufficient) 9.Site diagram or additional well details:
36.355978 79.922136 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&BEING ABANDONED SUBMITTAL INSTRUCTIONS ,
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
M W-3 abandonment to the following:
Division of Water Quality;Information Processing Unit,
6b.Total well depth: 62 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
well dia: 2 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: well abandonment to the following:
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6d.Water level below ground surface approX 40 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service CI nier,Raleigh,NC 27699-1636
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10c.For Water SunDIv&Iniection,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.
6g.Screen length(if known): (ft.)
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Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
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