Wilkes_Well Abandonment_20240918

WELL ABANDONMENT RECORD For lntemaI use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information: WELL ABANDONMENT DETAILI S
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-waier supply wells ONLY with the some
constructionlabandonmem,you can submit one form.
3322-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
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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 ❑Muriicipal/Public ❑Neat Cement Grout 173 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
❑hTi ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation bentonite chips: 1.6 ibs/ft(88ibs) r
❑Aquifer Storage and Recovery ❑Salinity Barrier ` �•.. ./ i� ,•
❑Aquifer Test ❑Stormwater Drainage L�24
❑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.RemoveT :�-.rade3J Surfa&.:'-.1'Uora
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) N��~A
4.Date well(s)abandoned:
5/28/2024
5a.Well location:
Helen Brown Property Incident 37784
Facility/Owner Name Facility ID#(if applicable) S•Certification:
1967 Sparta Road, North Wilkesboro Lawrence Opper'� 6/11/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wilkes By signing this fonn, I hereby certify that the wells)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:
36.221149 81.168387 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 constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
MW-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 55 qt,) 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: well abandonment to the following:
D Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface. Dry (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&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
6E Inner casing/tubing length(if known): 43 (ft.) where abandoned.
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6g.Screen length(if known): 12 (ft.) j
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013