Franklin_Well Abandonment_20231122

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WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
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Lawrence D. Opper I 2
PP 7a.Number of wells being abandoned:
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
construction/abandonment,you can submit one form.
• 3322-A
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):
0 Agricultural 0 Municipal/Public 2 Neat Cement Grout ❑ Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
❑Irrigation 0 Specialty Grout - ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g) -
21Monitoring ❑Recovery =-�. -.--
Injection Well: If.For each material selected above,provide amount of mate_r_ials used:, ', --';------.
.:...1 `J.1 kr-^'"i ..
❑Aquifer Recharge ❑Groundwater Remediation Grout: 1-2 gal./well
❑Aquifer Storage and Recovery 0 Salinity Barrier NU V 2 2" LUU23
• ❑Aquifer Test ❑Stormwater Drainage - -
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure::.?WZ. Lie
❑Geothermal(Closed Loop) ❑Tracer Tremie-filled from bottom-up. Cut casing flush to land surface
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
GPMW-4 15ft N36.03634.8, W78.503405
4.Date well(s)abandoned: 9/5/2023 . GPMW-8 27.5ft N36.034388, W78.506632
5a.Well location:
Former Diazit Company I
Facility/Owner Name Facility ID#(if applicable) 8.Certification: iv �r i , -
941 US Hwy1, Youngsville Lawrence O er: —,
9 PP ;,,";�,� 9/29/2023
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 well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well'details:
See 7gYou may use the back of this pagei`,to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
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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 construction/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,
• 15-27.5 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
lOb.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: well I.D.=1.0(in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality,U I
6d.Water level below ground surface: Dry (ft) derground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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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. I'
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
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Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013
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