Cumberland_Well Abandonment_20230724

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. We rl ey 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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
3344—A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1•82 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
W M 0601212 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknonn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑lndustriaVCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRefnediation Bentonite — 50 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StonnwaterDrainage Neat Cement�35 lbs.
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
[]Geothermal(Closed Loop) ❑Tracer
Gravity feed bentonite chips to 5' bgs
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
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Pour neat cement from 5' b(s°-'tLmd
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4.Date well(s)abandoned: 6/20/2023 °
5a.Well location:
Fayetteville(Raeford Roxie)W W,LLC a Delaware LLC NA
Facility/Owner Name Facility ID#(if applicable) 8.Certification: �Sr�tfl "
3611 Raeford Rd. Fayetteville, NC 28304f 7/18/2023
J �
Physical Address,City,and Zip Signature of Certified Well Contractor or Wel�owner Date
Cumberland 0417-70-7669
By signing this form, /hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 lVell Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.043342 N -78.94137 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
Attach uellconstructionrecord(s)ifavailable. For multiple injection ornon-rratersupplyrrells
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#: MW05 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 28.81 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
NA 10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) 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
6f.Inner casing/tubing length(if known): 20 (ft.) abandoned.
6g.Screen length(if known): 20 (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources) Revised 2-22-2016