Cumberland_Well Abandonment_20230915 (10)

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; 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
construction/abandonment,you can submit one form.
4308-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 'S
Bills 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 7d.Amount of disinfectant used: 1/4 lb
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ID Neat Cement Grout I ❑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 1, ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 45 lbS i, neat cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
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❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
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❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
•. .�•-. r Measured depth of well and SWL
3-14-23 . '` �.�i� �E
4.Date well(s)abandoned: Disinfected well i•
5a.Well location: SEP 1 2023 filled to top with cement
T A Loving Company
tin#vr 8.Certification:
Facility/Owner Name FacilW41W-iA plfcable)
7143 Stoney Point Rd, Fayetteville, NC 9 �„ 3-14-23
Physical Address,City,and Zip Signatuik of Certified Well Contractor br Well Owner Date
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Cumberland By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 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: I,
(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,
66.Total well depth 17 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
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10b.For Iniection Wells: In addition to sending the fort to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
13 Division of Water Quality,Underground Injection Control Program,
6d.Water level below,ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
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10c.For Water Suooly&Injection 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 Ito!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
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