Orange_Well Abandonment_20240710

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
construction'abandonment,you can submit one form.
3322-A
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 ❑Municipal/Public ❑ Neat Cement Grout; 0 Bentonite Chips or Pellets
❑ Sand Cem❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water SuPP1Y(single) ent Grbuh \. .. ' pay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout JUL1 1 V/� �p 1 Cuttings
❑Irri ation ❑ Specialty Grout L Cu24❑ Gravel
Non-Water Supply Well: ❑ Bentonite SILK, ❑'Joe
(explain under 7g)
OMonitoring ❑Recovery ryry}
Injection Well: 7f.For each material seleFtEd llbXr,'jrovide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation bentonite chips: 1.6 Ibs/ft(88 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)
4.Date well(s)abandoned: 5/20/2024
5a.Well location:
Midtown Shops DC680005
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
762 MLK Blvd. Chapel Hill Lawrence Opper „ 5/30/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Orange By signing this form, L 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:
35.924840 79.053149 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. Far multiple injection or non-water supply
wells ONLY with the same consiruction'abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-4 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 55 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:
approx 30 ft Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: —(ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
1Oc. For Water Suouly& 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
where abandoned.
6E Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form G W-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013