Bladen_Well Abandonment_20230315

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WELL ABANDONMENT RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lawrence D. Opper 7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abindoning•w"ell oq-his/hee propertyr For multiple injection or non-water supply wells ONLY with the same
i 1-„., construction/abandonment,you can submit one form.
NC 3322-A
NC Well Contractor Certification Number
MAR 1 5 2023 7b.Approximate volume of water remaining in well(s): (gal.)
Regional Probing Servicesln ,C,l FOR WATER SUPPLY WELLS ONLY:
Company Name -',`v L i_3'•�Y7
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,Stale,Variance,etc.)if 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 El Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
IZIMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 24bs.
❑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 1'of concrete.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 1/28/2023
5a.Well location:
Robert Brooks Site Incident# 13981
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
312 Martin Luther King Drive, Elizabethtown Lawrence Oppert" ,0, ° - 1/28/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bladen By signing this form, I hereby certifi)that the well(s) was (were) abandoned in
County Parcel Identification No.(PiN) accordance with I 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:
(dwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.626399 78.609537 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-wafer 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#:
MW-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 5 (ft.)
10b.For Injection 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: (in.) abandonment to the following:
approx 9 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&Infection 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
6f•Inner casing/tubing length(if known): 5 (ft.) where abandoned.
0
6g.Screen length(if known): 1 (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013