Cumberland_Well Abandonment_20230327 (4)

WELL ABANDONMENT RECORD Forlatcmal Usc ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
�an[ b t e CJ%ckr— 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the saute
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
31�- wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):_ 8 (gal.)
a e G o m FOR WATER SUPPLY WELLS ONLY:
Company Name
r 7c.Type of disinfectant used:
2.Well Construction Permit#: �l A
List all applicable well construction pernits(i.e.UIC.County,State.Flariance,etc.)ifb-noru
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7c.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(1-leating/Cooling Supply) ❑Residential Water Supply(single) Sind Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential W ❑ater Supply(shared) Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry - ❑Other(explain under 7g)
onitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge []Groundwater Remediation e) 3 a 1 b i (r T P 0Art fM t G-a-U.-J—
❑Aquifer Storage and Recovery ❑Salinity Barrier /'� )` 0
❑Aquifer Test ❑Sformwatc;J3raiGge-- „, (r/ 9 1 t►}' V"�
t❑Experimental Technology ❑Subsidcncc Confrol"-''°--i ,'J S^-`
t 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer MA qq r. 2023 t►hL� Srw�e (�O 't'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under g) ` e� b�f L ( a
4.Date well(s)abandoned: a 3 "t' x t i( pb v}CGVA
5a.Well location: -r('ty,^�r{
524e'j wuv A
Facff
ility/Owner Name c 1 facility ID#(if applicable) 8.Certification:
H 70 Gr e d L r G L!1J;*-'JCV,4• , $3°1 '�-�.� Q ►'-' • c . 2.3
Physical Address,City,and Zip t qL4. Signature of Ceni'ed Well Contmclor or Well Owner Date
twv-AS`� �By signing[his form, !hereby cerii(y tha[the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a cop),of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lit/long is sufficient) 9.Site diagram or additional well details:
3S. OrJ 1 N �8 .$ 6-7 '1 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attac•irHrltconsu-nctiaurecord(s)ifarailab&: For nndtipleh#ectiono•nar-watersupplj'wells
ONLY frith the saure coosu•uction/ahaadormeat,you can submit one forms.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: m 3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Alai]Service Center,Raleigh,NC 27699-1617
N l0b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
i
6d.Water level below ground surface: �' (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 2 7699-1 63 6
tic.Outer casing length(if known): PA (ft) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
�j of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): " (g,) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016