Person_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
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-water supply wells ONLY with the same
construction/abandonment,you can submit one form.
NC 3322-A - - „;
'76.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
Regional Probing Services MAR-9 5 2023 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)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 ❑MunicipaUPublic 0 Neat Cement Grout l Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
IJMonitoring ❑Recovery
Injection Well: - 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips:6.3 Ibs/ft(129-157 lbs/well)
❑Aquifer Storage and Recovery ❑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.
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
MW-1 (25') N36.400779, W78.976897
4.Date well(s)abandoned: 02/15/2023 MW-3 (20.5') N36.400368, W78.976926
5a.Well location:
Roxboro Concrete
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
121 Burch Ave, Roxboro 3/2/2023
Physical Address,City,and Zip SignaEo; rtifi; llC:nctororWellOwner Date
Person By signing this form, I hereby certfy 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:
36.400779 78.976897 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-1,MW-3 abandonment to the following:
Division of Water Quality,Information Processing Unit,
20.5 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 25, (ft.)
10b.For Injection Wells: In addition to sending the form to the address in 10a
well dia: 4 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
17' 13' Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
IOc. For Water Supply&Injection 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 casin tubin len th if known ft. where abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013