Robeson_Well Abandonment_20240116

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: 3
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.
NC 3322-A l
7b.Approximate volume of water remaining in well(s): 0 (gal.)
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.)ifknown 7d.Amount of disinfectant used
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mtmicipal/Public ❑Neat Cement Grout 91 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 b 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 ❑Groundwater Remediation Bentonite 1.6 Ibs/ft(21lbs/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)
MWA (20% MW-2 (19')!, MW-3 (19')
4.Date well 12/7/2023s)abandoned: � ����, ��:� �, •rd 6�,,,,�
5a.Well location:
Cecilia Shipman Property
8.Certification: �•r� 3�•
Facility/Owner Name Facility ID#(ifapplicable) j' trUir1' '2l ^a1•ti r�„
Highway 20 &State Road 1729, St. Pauls Lawrence O erg dGi^ i '� /11/2023
9 Y PP ,
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Daie
Robeson 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 be i n provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: J
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.844753 79.036112 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.
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CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS i
Attach well construction record(s)if available. For,mulriple injection or Rion-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#: See 7g abandonment to the following
Division of Water Quality,Information Processing Unit,
See 79 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b.For Infection Wells: In addition to sending the form to the address in 10a
well dia: 2 above,also submit one copy of.this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
approx 7 —(ft.) Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: ( ) 1636 Mail Service Center,Raleigh,NC 27699-1636
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10c.For Water Sunnly&Injection!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): 10 (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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WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Green
7a.For Geoprobe/DPT or Closed-L�op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4468-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 270 (gal.)
Charles R. Underwood Inc. FOR WATER SUPPLY WELLS ONLY:
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Company Name
7c.Type of disinfectant used: ,
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,Counry,State,Variance,etc)ifltnotwt 1'2oz
7d.Amount of disinfectant used:
3.Well use(check well use):
,
Water Supply Well: 7e.Sealing materials used(check all that apply):
eAgricultural ❑Municipal/Public ®Neat Cement Grout ❑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: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement j 2 Bags
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite 15 Bags
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Removed pump from well,jchlorinated well, ran tremie pipe
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
1/3/24 to bottom of well and grouted up, capped top of well
4.Date well(s)abandoned: r+ -
with neat cement grout;
5a.Well location:
Carmichael Farms 2624
Facility/Owner Name Facility ID#(if applicable) S.Certification:
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Fairley Rd, Maxton, NC 28364 .r�st.^�i�n ` `.` . U�2�rL DWO.r-I .O/9/24
Physical Address,City,and Zip Signature 6Kertified Well Co actor or Well Owner Date
Robeson 838423549700
By signing this form, I hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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:
(ifwell field,one lat/long is sufficient)
9.Site diagram or additional well details:
34.691227 N -79.391112 You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructionrecord(s)ifavailable.For multiple injection or non-watersupplywells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this'fotm within 30 days of completion of well
6a.Well ID#• 16 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 122 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter: 8 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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6d.Water level below ground surface: 19 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service C Inter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniectiori Wells: In addition to sending the form to 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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
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6g.Screen length(if known): (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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