Wake_Well Abandonment_20230109

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 abandon i d 5
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water I supply .,,Its ONLY with the same
NC 3322-A construction/abandonment,you can submit one form.
NC Well Contractor Certification Number
7b.Approximate volume of water re maining 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.)df known 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 21 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑'Sand Cement Grout El,Dry,Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout a S-Drill Cuttings
❑Irri ation ❑ Specialty Grout J q H'V N 0 q 202� Gravel
Non-Water Supply Well: El Bentonite Slurry l' J❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7£For each mat tat sele'cte above,-provide amount of materials used:
❑Aquifer Recharge []Groundwater Remediation Bentonite 1.6 Ibs/ft(32 Ibs/well)
❑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) El Other(explain under 7g)
MW-1 (20'); MW-2(20% MW-3(20'), MW-4(20'), MW-5(20')
4.Date well(s)abandoned: 11/23/2022
5a.Well location:
Jean's Starflite Incident#39679
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
5205 Hillsborough Street, Raleigh 'Lawrence Opp 12/13/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Raleigh 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 lat/long is sufficient) 9.Site diagram or additional well details:
35.791532 78.713105 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 available. For multiple injection or non-water supply
wells ONLY with the same construciion/abandonment,you can submit one form. 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: 20 (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 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: abandonment to the following: I'
approx 16-19 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&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): 5-10 (ft) where abandoned.
6g.Screen length.(if known): 10-15 (ft.)
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Form G W-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013