Wake_Well Abandonment_20230724 (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: 12
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ON/.Y with the same
constructionlabandonment,you can submit one form.
3322-A .
7b.Approximate volume of water remaining in well(s): 0
NC Well Contractor Certification Number
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.)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 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation bentonite chips:1.6 Ibs/ft(41-78 Ibs/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)
MW-1 R(29.5')MW-3(30.01')MW-4(28.55')MW-5(29.91')MW-6(34.38')
4.Date well(s)abandoned: 6/8/2023- MW-7(26.94')MW-8(26.97')MW-9(26.74')MW-10D(34.96')MW-11 (28.06')
5a.Well location: MW-13D(49.38),MW-14(10.25') E IV F
D±
National Guard CSMS-Raleigh
Facility/Owner Name Facility ID#(if applicable) 8.Certification
Y'%� J U L 2 A 20
-_ 6 3
4207 Reedy Creek Road, Raleigh Lawrence Opper;
2,,.;,L- 23
Physical Address,City,and Zip Signature of Certified Well Contractor or W 1l IYwner '�.D�t�!3ODate
Wake By signing this forni, 1 hereby certify that the tvell(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance ivith 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: i
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.8113225 78.7123284 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 ifnecessary.
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 consiruction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
Monitoring Wells-see 7g abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 26-49 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
Well I.D.=2.O above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: in.) abandonment to the following:
. approx 18 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
6E Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013