Wake_Well Abandonment_20230724 (4)

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: 1
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 constructionlabandonmeni,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.)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 ❑MunicipaVPublic ❑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: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation bentonite chips: 1.6 Ibs/ft(64 Ibs)
❑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)
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4.Date well 5/12/2023 s)abandoned:5a.Well location: JUL r A ZUZJ
Peggy's Cleaners r7cp 2_00)0 1 �tntcri-r470,n Ur.;
Facility/Owner Name Facility ID#(ifapplicable) 8•Certification: cm"Qaq
1605 New Bern Avenue, Raleigh Lawrence Opper' s as(�a3
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wake By signing this form, 1 hereby certify that the well(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 beet:provided to the well owner.
56.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:
35.780402 N 78.5615718 W You may use the back of this page to provide additional well site details or well
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 constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-3 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 40 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in l0a
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: approx 31 (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&Infection 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): 30 (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