Cumberland_Well Abandonment_20240419

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. We rl ey 7a.For Geoprobe/DPT or Closedi.00p Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW 130 is needed. Indicate TOTAL NUMBER of
3344—A wells abandoned:
1 .55
NC well Contractor Certification Number 7b.Approximate volume of wateri remaining in well(s): (gal.)
ECS Southeast, LLC FOR WATER SUPPLY WELLSONLY:
Company Name
2.Well Construction Permit#:
WM0601212 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc)ifknown
7d.Amount of disinfectant used:j
3.Well use(check well use): j
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 19 Neat Cement Grout X Bentonite Chips or Pellets
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout t ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout I ❑Gravel
Non-Water Supply Well: ❑ Bentonitc Slurry ❑Other(explain under 7g)
I lMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement —30 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite - 56 Ibs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of,'ttte abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer �
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite - gravity feed from 5 to 40 ft bgs
Neat Cement - po I r frq-Z f bgs to surface
4.Date well(s)abandoned: 3/1 9/2024
i 5a.Well location: APR 1 9 2024
Proposed WaWa N/A
Facility/Owner Name Facility ID#(ifapplicable) 8.C c U.0
3611 Raeford Road, Fayetteville, NC 28304 4/4/2024
Physical Address,City,and Zip Signature o rcd Wcll Co tract or Well Owner Date
Cumberland 0417-70-7669 By signing this,forin, I here y ce'rtify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C!01,00 or 2C.0200 IVell Construction Standards
and that a copy of this record has een 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
35.043321 N 78.941007
_ abandonment details._You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For rmdtiple injection or non-watersupply ivells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 —(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I
6d.Water level below ground surface: 30.49 (ft.) Division of Water Resources)Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft.) 10c.For Water Suaaly&Iniection 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
6f.Inner casing/tubing length(if known): 20 (ft.)
abandoned. I
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6g.Screen length(if known): 20 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016