Cumberland_Well Abandonment_20230915 (33)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells fl
1.Well Contractor Information: WELL ABANDONMENT DETAILS I
Sebastian Britt I
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-wafer supply ivells ONLY ivith the saine
construetion/abandomuent,you can submit one form.
4567-C r
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 23 (gal.)
Bill'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.)ifknow" 7d.Amount or disinfectant used:
''1,Ibs
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout 171 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: X For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 300 Ibs 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 . . .,
Removed pump equipment rS-y.. 7 s f�.. . `�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) �i_r ��'
Measured depth of well'and SWL
i c
4.Date well(s)abandoned: 4-3-23 Disinfected Well
Sa.Well location: filled to top with bentonite �" ; '`I`" `'�"''*==19 llr.
T A Loving Company
8.Ccrti tion:
Facility/Owner Name Facility ID#(if applicable)
�
8038 King Rd, Fayetteville, NC 4-3-23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Cumberland By signing this forn; I 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:
(if well field,one hit/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 hJection or not-water supply I,
wells ONLY with the same cmnstruction/abandonnnent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
69.Wel1ID11:
abandonment to the following: j
i
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 61 (ft.)
1617 Mail Service Center,Raleigh,NC 27699-1617
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 '
26 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 Supply&Iniectioo Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft-) the address(es) above, also submit bne copy of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned. I
611 Inner casing/tubing length(if known): (IL)
6g.Screen length(if known): 00
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013