Cumberland_Well Abandonment_20230915 (20)

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 ; 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-itvalcr supply wells ONLY tivith the same
4308-A construction/abandonnrent,you can subluitl one form.
7b.Approximate volume of water remaining in well(s): 15
NC Well Contractor Certification Number I i
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(11.e.County,State,Variance,etc.)iflarown ! 1 I bs
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout i El Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ' ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
ElIrri ation ❑ Specialty Grout j• ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry i ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 300 Ibs bentonite chips
❑Aquifer Storage and Recovery ❑Salinity Barrier i
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
[]Geothermal(Closed Loop) ❑Tracer pulled pump from well
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
�, Measured depth of well and SWL
4.Date well(s)abandoned: 5-16-22 z"ti Rw ``� Disinfected well
.y
5a.Well location: S E P 1 ; 2023 filled with bentonite chips
TA Loving Company
Facility/Owner Name ID�I%dc'r7iiy�IDtk�'fe I �'e ' 8*Certification:
2106 Pinewood Terrace, Fayetteville, �� 28304 5-16-22
Physical Address,,City,and Zip Signaturgof Certified Well Contractor or Well Owner Date
Cumberland By signing this form, I hereby certify that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance ivith 1 SA 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:
(if well field,one latllong is sufficient) 9.Site diagram or additional well details:
35.024876 -79.022481 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 we!l construction records)if available. For nmltiple injection or nor-water supply
wells ONLY with the same constructio✓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: 55 (fL) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form 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:
I
• 32 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 Suonly&Iniection Wells: In addition to sending the form to
6e.Outer casing length(it known): �R•) 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
6E Inner casing/tubing length(if known): (%) where abandoned.
6g.Screen length(if known): UP
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

f �
WELL ABANDONMENT RECORD [7t
ONLY: 4
This form can be used for single or multiple wells I(
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Borror 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple b jection or non rivo
4308-A ter supply wells ONLY with the same
construction/abandonment,you can su!,one form.
I
NC Well Contractor Certification Number 7b.Approximate volume ofwatlr remaining in well(s): 21 (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.)ifknown 7d.Amount of disinfectant used 1 lbs
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout j El Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
DIrri 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 ❑Groundwater Remediation 425 lbs bentonite chips
❑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 pump from well
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
a I—�� Measured depth of well and SWL
5-16-22 R E C # is L i-d
4.Date well(s)abandoned: 1 Disinfected well
1
5a.Well location: SEP 5 2023 filled with bentonite chips
TA Loving Company Itwa as a ir"n C-Jr - t;+ n*Ur.�
Facility/Owner Name Facility IU9;(jfi,1p"[ilica�ilo) a•Certification:
7603 Alameda Dr., Fayetteville, NC 28304 5-16-22
Physical Address,City,and Zip Signature WCertified Well Contractor or Well Owner Date
Cumberland By signing this form,I hereby certify that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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:
35.028235 -79.019931 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 Infection or non-water supply
svells 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: 74 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In add tion to sending the form to the address in 10a
6c.Borehole diameter: (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I
41 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 Supply&Injection 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 abandonment to the county health department of the county
where abandoned. i
6E Inner casing/tubing length(if known): (ft.) I
I ,
6g.Screen length(if known): (fL)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
I

� I
WELL ABANDONMENT RECORD ForinternalUseONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Borror i 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 pwa(er supply wells ONLY ivith the same
constructioWabandonment,you can submit one form.
4308-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 12 (gal.)
Bills Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: MTH
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)iflmown 7d.Amount of disinfectant used, 1 I bS
I
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural OMunicipaUPublic ❑Neat Cement Grout El Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) O Sand Cement Grout i ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
ElIrri 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 350 lbs ; bentonite chips
❑Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description ofithe abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) pump from well
❑Other(explain under 7g)�, _„i ` r, Measured depth of well,and, SWL
4.Date well(s)abandoned: 5-2-22 P� — ate,,fi_�l G°' Disinfected well
5a.Well location:' SCP 1 2023 filled with bentonite chips
TA Loving Company ,r
t '- 8.Certification: I
Facility/Owner Name lrF�tit�T>i�ref��jcp�le�`T� ,
7700 Siple Ave, Fayetteville, NC 280'4 L -ZL- 5-2-22
Physical Address,City,and Zip Signatur of Certified Well Contractor of Well Owner Date
Cumberland By signing this form, I hereby certify that the well(s)ivas(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 ivell 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 well details:
35.026044 -79.025133 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 constructioWabandonment,you can submit one form. 10a. For All Wells: Submit this tform within 30 days of completion of well
6a.Well IB#:
abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 57 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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:
6d.Water level below ground surface: 39 (ft.) Division of Water Quality,U Iderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
6e.Outer casing length(if known): (ft) loc.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit tine copy of this form within 30 days of
completion of well abandonment to the county health department of the county
6L Inner casing/tubing length(if known): 65 (%)
where abandoned. !
6g.Screen length(if known): 4
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013