Cumberland_Well Abandonment_20230915 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY: f
This form can be used for single or multiple wells j
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Sebastian Britt I ' 1
7a.Number of wells being abandoned:
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
4567-C construction/abandonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of w I te'r•remaining in well(s): 32 (gal.)
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Blll's Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
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Company Name 7c.Type of disinfectant used:,,HTH
2.Well Construction Permit#:
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.Seating materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑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 350 Ibs i bentonite ehipps
❑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 Pulled pumping equipment
❑Geothermal(HeatingtCooling Return) ❑Other(explain under 7g)
Measured depth of well and SWL
4.Date well(s)abandoned: r' V t_—�- Disinfected well
5a.Well location: SEP 1 2023 filled to top with bentonite
T A Loving Company
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Facility/Owner Name Facility MPAjPCaff0k1b) 8•Certification:
7189 Stoney Point Rd, Fayetteville, NC pp 3-8-23
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Physical Address,City,and Zip Signature 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:
(ifwell field,one[at/long is sufficient) 9.Site diagram or additional well details:
34.9831531 -79.020277$ 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.
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CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
welts 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#: i
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 69 (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
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6d.Water level below ground surface 20 (ft.) Division of Water Quality,'Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Suooly&Inielction Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonmeri to the county health-department of the county
6L Inner casingttubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
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Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013