Cumberland_Well Abandonment_20230915 (42)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Borror I
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
NC Well Contractor Certification Number
7b.Approximate volume of wp t Ir remaining in well(s): 523 (gal.)
Blllrs Well Drilling Co. FOR WATER SUPPLY WELT LS ONLY:
Company Name 7c.Type of disinfectant used- IHTH
2.Well Construction Permit#: I
List all applicable well construction permits(i.e.County,State,Variance,etc.)iflmown 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 ❑Municipal/Public ❑Neat Cement Grout ! ❑Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑ Sand Cement Grout Rl Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 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 3 yards sand clay
❑Aquifer Storage and Recovery ❑Salinity Barrier
1/2 Yard Concrete
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Measured depth of well and SWL; pumped water out of well
❑Geothermal(Heating/Cooling Return) ❑Oth r� .explairr-ggdeF 79) W..,
- ,ii..
ti .+,,L: �� J Disinfected well; filled with sand clay.
4.Date well(s)abandoned: 6-30-23 S E P 1 5 2023 Removed top 3 ft of well casing
5a.Well location: Topped with cement cap
IRivr3f"2Mt�rl ['''�:".;�a�.'ti':iq lit:)i
Bob Doran p'f1(:;1�113G .
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1229 Middle Road, Eastover, NC 28312 6-30-23
Physical Address,City,and Zip Sign a of Certified Well Contractor or Well Owner Date
Cumberland 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 well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
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 construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID#:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
40 (ft.) 1617 Mail Service i Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 20 (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
$ Division of Water Quality,,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service',Center,Raleigh,NC 27699-1636
10c.For Water Sunuly&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.
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013