Nash_Well Abandonment_20230315

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
I '
Lawrence D. Opper 7a.Number of wells being abandoned: 2
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-router supply wells ONLY with the same
construction/abandonment,you can submit one form.
NC 3322-A 0
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
Regional Probing Services MAR 1 5 2023 FOR WATER SUPPLY WELLS ONLY:
Company Name Ur,:t 7c.Type of disinfectant used:
rI o:tea':i'•..:Z7
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,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 IZ1 Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑ Drill Cuttings
❑irrigation 0 Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
IZ1Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 48bs.
0 Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage - —
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Filled/hydrated from bottom-up. Capped with concrete.
0 Geothermal(Heating/Cooling Retum) 0 Other(explain under 7g)
4.Date well(s)abandoned: 1/6/2023
5a.Well location:
RW Hull Grocery
Facility/Owner Name Facility ID#(if applicable) 8.Certification
205 S. White Street, Whitakers Lawrence O er,` ^°�°—°
pp 1/11/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Nash By signing this form, I hereby certi&that the well(s) was(were) 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.10355727 77.715952 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#: MW-4, MW-5 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth 15 (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: (in.) abandonment to the following:
6d.Water level below ground surface: approx 4.5 (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
2 where abandoned.
6E Inner casing/tubing length(if known): (ft.)
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6g.Screen length(if known): 13 (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013