Carteret_Well Abandonment_20240918

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: 2
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
constructionlabandomneni,you can submitione 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,Slate,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):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout il 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)
2Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation bentonite chips:1.6 Ibs/ft(24 lbs/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-4R (16), MW-8 (15r)
4.Date well(s)abandoned. 6/14/2024 I:
5a.Well location: P 1 8 2024
C-Mini Mart#5 ;. t
Facility/Owner Name Facility ID#(ifapplicable) $•Certification: Qt h! ^ ,J,s
184 NC Highway 24, Morehead City Lawrence er,. �Ca /
9 Y Y � pP , t���i�.�°" '°�"`"` 6/30/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Carteret By signing this form, I hereby certify that the wells)was'(Were) abandoned in
County Parcel Identification No.(PIN) accordance ivith 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 lat/long is sufficient) 9.Site diagram or additional well details:
34.734692 76.801412 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. For multiple injection or non-water supply
wells ONLY with the same construciion/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,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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
6c.Borehole diameter: (in.) abandonment to the following:
approx 7 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface. (ft.) 1636 Mail Service Center;Raleigh,NC 27699-1636
10c.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
6E Inner casing/tubing length(if known): 5 (ft.) where abandoned.
6g.Screen length(if known): 10
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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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