Cumberland_Well Abandonment_20230915 (14)

WELL ABANDONMENT RECORD For Internal Use ONLY: l
This form can be used for single or multiple wells
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jonathan Kamionka 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 jwuiter supply wells ONLY with the same
construction/abandomnent,you can submit one form.
3465-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 40 (gal.)
Blllrs 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)ifknown 7d.Amount of disinfectant use
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 21 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) FiResidential 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
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❑Experimental Technology ❑Subsidence Control 7g.Provide a brief-description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer removed pump
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
x`9'=� 4 Measured depth of well and SWL
4.Date well(s)abandoned: 3-14-23 Fill" 2023 Disinfected well
5a.Well location:
SEP 1 filled to top with bentonite
T A Loving Company
Facility/Owner Name Facility #(i apcabl plie) $•Certification:
7714 King Rd, Fayetteville, NC 3-14-23
Physical Address,City,and Zip SiguattYre of Certified Well Contractor br Well Owner Date
Cumberland By signing this form, I hereby cert fy that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C 10100 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 lattlong 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 ��' abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONEDSUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLYwith 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:
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Division of Water Quality,Information Processing Unit,
6b.Total well depth: 68 (ft.)
1617 Mail Service Center,Raleigh,NC 27699-1617
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10b.For Infection Wells: In addition to sending the form to the address in 10a
4 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following: I
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20 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) Division
Mail Service Center,Raleigh,NC 27699-1636
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loc.For Water Summly&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 lto,the county health department of the county
6f.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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