Orange_Well Abandonment_20240306

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. O er i 7
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 I
7b.Approximate volume of water remaining in well(s): 0 (gal.)
NC Well Contractor Certification Number 1
Regional Probing Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.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 Rl Bentonite Chips or Pellets
❑Geothermal(HeatinglCooling 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)
RIMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation bentonite chips:1.6 Ibs/ft(20-64lbs/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(30'),MW-2(23'),MW-3(20'),MW-4(20'),MW-51)(40'),MW-6(25'),MW-7(25')
4.Date well 2/9/2024s)abandoned: � "' '?;�, s't �{'•r,,�
Sa.Well location: !
Former Chips Auto MAN4
Facility/Owner Name Facility ID9(ifapplicable) 8•Certification:
5309 Groucho Road, Durham Lawrence Oppe;
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Orange 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 jn 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:
36.035721 79.007365 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. !'or 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#: Monitoring Wells-see 7g abandonment to the following:
i
Division of Water Quality,Information Processing Unit,
20-40 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 10a
well I.D.=2.0 above,also submit one copy of this form within 30 days of completion of well
6e.Borehole diameter: (in.) abandonment to the following: I
6d.Water level below ground surface: 12 (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
loc. For Water Supply&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): (ft.)
I
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Q I lity Revised March 2013