Cumberland_Well Abandonment_20240429 (6)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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L Well Contractor Information: WELL ABANDONMENT DETAILS
Ken Dledlker, 7a:For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name"(or well owner personally abandoning well ou his/her propeity) well cotistruction/depth,only 4 GW-k is needed. Indicate TOTAL NUMBER of
n/a (federal employee) wells abandoned:+ I
NC Well Contractor Certification Number 7b.Approximate volume'of water remaining in well(s):
US Army.Corp of:Engineers, Savannah District FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.)if"own
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 a 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
[Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry O Other(explain under 7g)
NMonitoring ❑Recovery.
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 2 ba
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OAquifer 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
❑Geothermal(Heating/CoolingRetum) ❑ocher(explain under 7g) Bentonite chips poured into borehole and hydrated.
4.Date well(s)abandoned: 02/28/2024 ^'
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5a.Well location:
US Army.- Ft. Liberty ; •c ;nth
Facility/Owner Name Facility ID# ifa licable 8.Certification: URIX
407th BSB Motor Pool,off Yorktown Victor Rd, Fort Liberty,28307 DIEDIKEa.KENNETH.D.760723598 �.24'.5 .­�w 04/23/2024
Physical Address;City,and Zip Signature of Certified Well Contractor or Well Owner Date
Cumberland By signing this form, I hereby certify that the ivell(s) i,vas(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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latAong is sufficient) 9.Site diagram or additional well details:
35.124101 N 79.025590 `l You may use the back of this page to provide additional well site details or well
abandonment details. You may also'attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBbIITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandoument,you can submit one form.
10a. For All Wells: -Submit this form within 30 days of completion of well
6a:Well ID#: C-8727A-RW-5R abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25.5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the.form to the address in 10a
6c.Borehole diameter 4.25 (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 '17 (ft.) ' . -Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 25.5 (ft) 10c.For Water Suaaly&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
611 Inner casing/tubing length(if known): (ft.) - abandoned.
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6g.Screen length(if known): 10
Form GW-30 North.Carolina Department of Environmental Quality-Division of WaterResources Revised 2722-2016
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