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HomeMy WebLinkAboutCumberland_Well Abandonment_20230915 (39) WELL ABANDONMENT RECORD For Internal Use ONLY: This form can be used for single or multiple wells I 1.Well Contractor Information: WELL ABANDONMENT DETAILS Joshua Borror 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-water supply ivells ONLY with the same constructlaWabandonment,you can submit one form. 4308-A 7b.Approximate volume of water remaining in well(s): 39 (gal.) NC Well Contractor Certification Number I i Blll's Well Drilling Co. FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: HTH 2.Well Construction Permit#: List all applicable ivell construction permits ri.e.County,State,Variance,eta)iflatown 7d.Amount of disinfectant used:: 1 Ibs 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout Rl Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) IdResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay ❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings ❑Irri ation ❑Specialty Grout i ❑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 ❑Groundwater Remediation 425lbS bentonite []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 ❑Geothermal(Heating/Cooling Return) El Other(explain under 7g) Measured depth of well and SWL 4.Datewell(s)abandoned: 3-14-23 Disinfected well Sa.Well location: SEP 1 5 20D filled to top with bentonite NC DOT Facility/Owner Name Iltl adi&f¢"It5#f f��ppij�a 8.Certification- NO &�� ROAD ��-�k 3-14-23 Physical Address,City,and Zip Signs of Certified Well Contractor or Well Owner Date Cumberland By signing this form, I hereby certify that the ivell(s)ivas(were)abandoned in County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards and that a copy of this record has been provided to the ivell owner. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one Iattlong is sufficient) 9.Site diagram or additional well details: 34.965618 -79.017305 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. i CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS' Attach well construction record(s)if available. For multiple injection or non-water supply wells ONLYivith 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#: abandonment to the following: Division of Water Quality,Information Processing Unit, 6b.Total welt depth: 81 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Infection Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter: 4 (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: 21 (ft.) Division of Water Quality,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 10c.For Water Supply&Iniecl on Wells: In addition to sending the form to 6e.Outer casing length(if known): (fL) 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 Innercasing/tubing length(if known): (ft.) where abandoned. 6g.Screen length(if known): (ft.) Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water(Quality Revised March 2013 I I ' WELL ABANDONMENT RECORD For Internal Use ONLY: This form can be used for single or multiple wells 1.Well Contractor Information: WELL ABANDONMENT DETAIILS Joshua Borror 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-water supply wells ONLY with the same construction/abandonment,you can submit one form. 4308-A i NC well Contractor Certification Number 7b.Approximate volume of waterlremaining in well(s): 24 (gal.) Bills Well Drilling Co. FOR WATER SUPPLY WELLS:ONLY: Company Name lc.Type of disinfectant used: HTH 2.Well Construction Permit#: List all applicable well construction permits 0.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used i, 1 l bs 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 21 Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑ Sand Cement Grout 1, ❑Dry Clay ❑lndustriaVCommercial ❑Residential Water Supply(shared) ❑Concrete Grout j ❑Drill Cuttings [Irrigation ❑ Specialty Grout ❑Gravel Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g) ❑Monitoring ❑Recovery Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation 300lbs bentonite ❑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 ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) _ � - Measured depth of well and SWL F% � � 3-14-23 � �.' �.'" 4' �..� a.Date well(s)abandoned: Disinfected well EP 1 � 2023 Sa.Well location: S filled to top with bento.nite NC DOT _ I S. Facility/Owner Name Facility ID#(f a�p'"irAd�e Certification. NO ROAD ; 3-14-23 Physical Address,City,and Zip Sigaa of Certified Well Contractor or Well Owner Date Cumberland I. By signing this form,I hereby certify 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 ivell owner. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i (ifwell field,one laMong is sufficient) 9.Site diagram or additional well'details: 34.3966346 -79.022669 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 records)if available. 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#: abandonment to the following: Division of Water Quality,Information Processing Unit, 6b.Total well depth: 53 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Iniection Wells: In addition to sending the form to the address in 10a 4 above,also submit one copy of tliis'form within 30 days of completion of well 6c.Borehole diameter: in.) abandonment to the following: 16 Division of Water Quality,Underground Injection Control Program, 6d.Water level below ground surface: (fr) 1636 Mail Service Center,Raleigh,NC 27699-1636 i i 10c.For Water Sunaly&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 6E Inner casing/tubing length(if known): ( ) where abandoned. 6g.Screen length(if known): (ft.) Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013 I