Cumberland_Well Abandonment_20230915 (9)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jonathan Kamionka 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 Yal ter supply wells ONLY with the same
3465-A
construction/abandonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of water iemaining in well(s): 40 (gal.)
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 well construction permits(i.e.County,State,Variance,etc.)tj/mown 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 El 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: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 350lbs 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 Removed pump
❑Geothermal(Heating/Cooling Return) ❑Other(exp aln u"nnen)^-
k-., V r—Measured depth of well and SWL
a.Date well(s)abandoned: 3-14-23 SEP I ; 2023 Disinfected well
5a.Well location: IRf�; a; pled to top with benonite
T A Loving Company DIA C;ncx;
Facility/Owner Name Facility 1D#(if applicable) 8•Certification:
7179 Stoney Point Rd, Fayetteville, NCk,6:1,_4IK 3-14-23
Physical Address,City,and Zip Sign#urJ of Certified Well Contractor'or Well Owner Date
Cumberland By signing this form, 1 hereby certify that the ivell(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 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: 53 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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.
24 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft) 10c.For Water Suuoly&Iniechon 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 abandonments to the county health department of the county
6E Inner casing/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

WELL ABA1NDUAMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jonathan KamionlCa 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
3465-A construction/abandonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of w ate l remaining in well(s): 40
Blll's Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown I 1 lbs
7d.Amount of disinfectant used:•
I
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout El Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential 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: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 350lbs ; 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 Removed pump r
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Measured depth of well and SWL
i ! er•-a
4.Date well(s)abandoned: 3-14-23 R. El'�V Disinfected well
i .
5a.Well location: SEP 1 5 2023 filled to top with benonite
T A Loving Company
1 r11~'ZTR-�i^Sl fir,reos.%a c.f � ;
Facility/Owner Name Facility IL�."(ffa5licybl� 8.Certification:
7127 Stoney Point Rd, Fayetteville, NClxk� 3-14-23
Physical Address,City,and Zip Si tune of Certified Well Contractor or Well Owner Date
Cumberland By signing this form, I hereby certify that the tvell(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 NCAC 02Q.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: `
(if well field,one lat/long is sufficient) 9.Site diagram or additional we r 11 details:
You may use the back of this page.to provide additional well site details or well
N ��' 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
6a.Well ID# abandonment to the following:
• Division of Water Quality,Information Processing Unit,
6b.Total well depth 59 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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:
6d.Water level below ground surface: 20 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&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. i
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013