Granville_Well Abandonment_20230825

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
constructionlabandonment,you can submit one form.
3322-A '
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (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 all that apply):
❑Agricultural ❑MunicipaUPublic ❑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)
Monitoring ❑Recovery
Injection Well 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation bentonite chips:40 lbs.
❑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) 00ther(explain under 7g)
I
4.Date wcll(s)abandoned: 7/4/2023
5a.Well location:
Creedmoor BP
Facility/Owner Name Facility ID#(ifapplicable) 8•Certification:
101 N. Main Street, Creedmoor Lawrence Opp
ep k_z 7/5/2023
m�s
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Granville 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 well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I '
(ifwell field,one Tat/long is sufficient) 9.Site diagram or additional well!details:
36.117822 78.686591 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 WELLS)BEING ABANDONED ,, ;.�-SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple it a or n"')or-�;atejs`lr d-
wells ONLY with the same construction/abandonment,you cans iil((�`ii V+ 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-1 MG 2 5.2023 abandonment to the following:
�(A Division of Water Quality,Information Processing Unit,
WO
6b.Total well depth: 25 (ft.) VA 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.=2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following: j
6d.Water level below ground surface:' 9 (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
6f.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