Cumberland_Well Abandonment_20230915 (35)

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 7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple it jection or non-water, supply wells ONLY ividr 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): 25 (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 ivell construction permits(i.e.County,State,Variance,etc.)ifknmvn 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 ❑MunicipaVPublic ❑Neat Cement Grout El Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) DResidential 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 325 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 Removed pump equipment
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) - � t
Measured depth of well and SWLf�;, �" :�1�
4.Date well(s)abandoned: 4-3-23 Disinfected WeII
5a.Well location: filled to top with bentonite Ur:T(
T A LovingCompany aINVIC-1D 0 -. �
P y S.Certification: In+ ' �����`�
Facility/Owner Name Facility ID#(if applicable)
7169 Stoney Point Rd, Fayetteville, NC 4-3-23
Physical Address,City,and Zip Sign ape,of Certified Well Contractor or Well Owner Date
Cumberland
By signing this form, I hereby certfy;that the ivell(s)was(tivere)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:
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. ror multiple infection or non-water supply
wells ONLY ivith the same construction/abandonnnent,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: 63 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
100.For Iniection 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
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
6E Innercasing/tubing length(it known): (ft)
where abandoned.
I
6g.Screen length(if known): (ft.)
i
I
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Sebastian Britt . 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-rPater supply wells ONLY with the same
constructioWabandonment,you can submit one form.
4567-C ►
NC Well Contractor Certification Number 7b.Approximate volume of water'remaining in well(s):28 (gal.)
Bills Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
I
2.Well Construction Permit#:
List all applicable well construction permits(1.e.County,State,Variance,etc.)ifknown 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 ❑MunicipaVPublic ❑Neat Cement Grout El Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ZResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
[]Irrigation ❑ 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 425lbs 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 equipment
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
^-� Measured depth of well and SWL
4.Date well(s)abandoned: 3-23-23 4 \�' �� �°�f Disinfected Well
5a.Well location: SEP 1 F 2023 filled to top with bentonite
Eugene Melton _ �r�.ry�yr.',a urn
Facility/Owner Name acihty noffefi $•Certif on:
403 Ladley St, Fayetteville, NC ; 3-23-23
Physical Address,City,and Zip Signature ofCertified Well Contractor or Well Owner Date
Cumberland 0426-80-6489 By signing this form, I hereby certify that the ivell(s) wvas(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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 lat/long is sufficient) 9.Site diagram or additional well details: -
35.0152434 -79.9041244 You may use the back of this page to provide additional well site details or well
N �1' abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)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: 81 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection 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: 23 ( ) Division of Water Quality,Underground Injection Control Program,
1636 Mad 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): (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): (ft.) where abandoned.
6g.Screen length(if known): (fL) i
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013