Franklin_Well Abandonment_20230602 (2)

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 ofwells being abandoned. 21
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply welts ONLY with the same
3322-A construction/abandonment,you can submit one form.
7b.Approximate volume of water remaining in well(s): 0 (gal.)
NC Well Contractor Certification Number
Regional Probing Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknoum 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 IZI Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout` - ^A' a y G��till Cuttin s
❑Industrial/Commercial ❑Residential Water Supply(shared) u y� g
❑Irri ation El Specialty Grout CJ"GtaSel
202
2
Non-Wat;r Supply Well: ❑ Bentonite Slurry 1111 G 7 Other(explain under 7g)
❑Monitoring RlRecovery
Injection Well: 7E For each mat$gkli§eIp tetlltabovet Rraw de}► olunt of materials used:
❑Aquifer Recharge ❑Groundwater Remediation bentonite chips:1.6 Ibs/ft(3�+Ili's�t!✓ell)?
❑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/hygrated from bottom-up. Capped with concrete.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Vapor Extraction Wells: VE-1 through VE-21
4.Date well(s)abandoned: 4/26/2023-4/27/2023
5a.Well location:
Cary Oil#19(ET's Quick Stop) NCDEQ Incident#24434
Facility/Owner Name Facility ID#(ifapplicable) 8•Certificatio
5703 NC Hwy 96, Youngsville Lawrence Op er;' 5/10/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Franklin 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:
36.0446544 78.503031 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 ivilh 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#• Vapor Extraction Wells-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 I.D.=2.0 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 >20 (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
where abandoned.
6E Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013