Franklin_Well Abandonment_20230602 (3)

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: 18
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
3322-A construction/abandonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
Regional Probing Services 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)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check till that apply):
❑Agricultural ❑MunicipaUPublic ❑ Neat Cement Grou '. .;_ OBpn_t rite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grou y, , all5rj?Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 11I r. ❑ rill Cuttings
❑irri ation ❑ Specialty Grout J U U v 2 20dravel
Non-Water Supply Well: ❑ Bentonite SlurrylD I i,, yy,,P,� tLt�wxplain under 7g)
❑Monitoring ❑Recovery CIO
Injection Well: 7E For each material selectee a`ti ve,provide amount of materials used:
❑Aquifer Recharge El Groundwater Remediation bentonite chips:1.6 Ibs/ft(38-64lbs/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)
AS-1(35')AS-2(35')AS-3(36')AS-4(34')AS-5(35')AS-6(35')
4.Date well(s)abandoned: 4/26/2023-4/27/2023 AS-7(35')AS-8(35')AS-9(35')AS-1 0(35')AS-1 1(35')AS-1 2(34')
5a.Well location: AS-1 3(34')AS-1 4(35')AS-1 5(26')AS-1 6(35')AS-1 7(24')AS-1 8(40')
Cary Oil#19 (ET's Quick Stop) NCDEQ Incident#24434
Facility/Owner Name Facility ID#(ifapplicable) 8•Certification: -
5703 NC Hw 96, Youn sville Lawrence O er'� -m~
y g p ,�"`°�"' 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 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell 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 ONI,Ywith 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#: Air Sparge Wells-see 7g abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 24-40 (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:
I
22 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&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.
6g.Screen length(if known):
I I
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013