Wake_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 abandonled 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-wafer supply wells ONLY with the same
eonstructionlabandonmem,you can submit one form.
3322-A
7b.Approximate volume of water remaining in well(s): 0
NC Well Contractor Certification Number (gal.)
Regional Probing Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Ca(OCI)2
2.Well Construction Permit#: GW 12071-2024
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: 2 OZ
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
❑Geothermal(Heating/Cooling Supply) EIResidential 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: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation bentonite chips: 800 Ibs - -• .
❑Aquifer Storage and Recovery ❑Salinity Barrier 'd._.x,. �.•�; ':� t
❑Aquifer Test ❑Stormwater Drainage HIP
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure: 2�24
❑Geothermal(Closed Loop) ❑Tracer Disinfected well prior to abandonment.Nell pump anti'6rptngf&er8ipr6viously4gmoyed
J'e.:
❑Geothermal(Heating/Cooling Return) El Other(explain under 7g)
Filled and hydrated from bottom-up. Beintonite chips were pre-screened to remove fines.
4.Date well(s)abandoned: 6/28/2024 Capped with concrete to prevent surface expansion.
5a.Well location:
Tower Improvements,LLC c/o DLC Mgt Corp.
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
3625 New Bern Avenue Lawrence Opper' 7/4/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wake By signing this form, I hereby cert�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:
(ifwell field,one fattlong is sufficient) 9.Site diagram or additional well details:
35.797155 78579872 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 avatlahle. 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#: Supply Well abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
71 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
well I.D.=6.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
I
27 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Cc nter,Raleigh,NC 27699-1636
IOc. For Water Summlv&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
6f.Inner casing/tubing length(if known): (ft.) where abandoned. I ,
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013