Wake_Well Abandonment_ (5)

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: 9
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-wager, supply wells ONLY with the same
construction/abandonment,you can subindone form.
NC 3322-A -
7b.Approximate emainin in • 0 al.
NC Well Contractor Certification Number pp volume of water r I gn we () (gal.)
Regional Probing Services Q iQ7� 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,1rri'nce,etc.)ifknavvn
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
❑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)
OMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite chips:2•MW:1.6 Ibs/ft(32-112lbs/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) ❑Other(explain under 7g)
MW-2 (17.4'), MW-5D (50'),MW-6 (20'), MW-7 (20')
4.Date well(s)abandoned: 11/23/2022 MW-9(20'), MW-10(20'), MW-11 (20'),M-12D(70') MW-13(20')
Sa.Well location:
The Little Bar
Facility/Owner Name Facility ID#(ifapplicable) 8•Certification:
2901 US Hwy64 West Lawrence O e � °° ° �
pp 12/13/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wake By signing this form, I hereby certify that the well(s) was(here) 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:
(ifwell field,one hit/long is sufficient) 9.Site diagram or additional well details:
35.74503392 78.908483 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 construction/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,
174-70 1617 Mail Service Center,Raleigh,NC 27699-1617
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6b.Total well depth: (ft.)
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10b.For Iniection Wells: In addition to sending the form to the address in l0a
well dia: 2 above,also submit one copy of this"form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface approX 8-1 1 (ft) Division of Water Quality,Underground Injection Control Program,
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
611 Inner casing/tubing length(if known): (ft.) where abandoned. F
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