Cumberland_Well Abandonment_20240419 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAIL'S
Scott M. Werley 7a.For Geoprobe/DPT or ClosedlLoop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
3344-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of wate'remaining in well(s): 1 .73 (gal.)
ECS Southeast, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7e.Type of disinfectant used:
2.Well Construction Permit#:
W M 0601212
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc)ifknown
7d.Amount of disinfectant used
r
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public C Neat Cement Grout a Bentonite Chips or Pellets
❑Geothenmal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bcntonite Slurry ❑ Other(explain under 7g)
IMMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Neat Cement —30 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier Bentonite "' 56 Ibs
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedure:
I
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite - gravity feed from 5 to 40 ft bgs
Neat Cement - pour from 5 ft bgs to surface
4.Date well(s)abandoned: 3/1 9/2024
5a.Well location: L:t.. jw: 'Vj
Proposed WaWa N/A °r
APR 19 2OZ4
Facility/Owner Name Facility lD#(ifapplicable) S.Certifieation:
3611 Raeford Road, Fayetteville, NC 28304 RY4/4/2024
Physical Address,City,and Zip Signature of 'citified Well Victor or Wdl Owncr Date
Cumberland 0417-70-7669 By signing this form, I hei certfy that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C:0100 or 2C.0200 GVell 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:
(ifwcll field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.043321 N 78.941007 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach ivell constrttctiott record(a)ijavailable. Fa•nudtiple injection or non-1vatersopply wells
ONLY with the same constA•action/ahandanment,volt can submit one font.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (ft) 1617 Mail Service Center,enter,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:
6d.Water level below ground surface: 29.38 (ft.) Division of Water Resources;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NIA (ft) 10c.For Water Supplv&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
6g.Screen length(if known): 20 A)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016