Cumberland_Well Abandonment_20240731

WELL ABANDONMENT RECORD For Internal Use ONLY:
L Well Contractor Information: W'F.LL:IBANDONMENT DETAILS
K. Brandon Moore 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I G W-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
2957-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
7c.Type of disinfectant used: Calcium
2.Well Construction Permit#:
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.)if known 8 oz.
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 ❑ Bentonite Chips or Pellets
❑Geothermal(Fleating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) e Concrete Grout ❑ Drill Cuttings
❑Irri gation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete grout 2.5 cubic yards
❑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 Poured concrete directly into well casing
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 g)
and filled to within 3 feet of land surface and
4.Date well(s)abandoned: 7/17/24 installed 18-inch thick concrete cap on top.
5a.Well location:
NC DOT N/A
Facility/Owner Name Facility ID!(if applicable) 8.Certification:
6109 Rockfish Road ?, . i'Z957- A 7/17/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Hope Mills, NC 28348 0404-76-1025
By signing this form, 1 hereby certify that the well(s) was (were)abandoned in
County Cr,-+ram Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well rdngiVuion 4hun4o(ds
and that a copy of this record has been provided to the welt otyra�',x . ! 7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details: I���a,,
34.975376 N 78.976155 W You may use the back of this page to provide additional wells is or
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
Auachwellc•onstrucnonrecord(r)ijm,ailahle. hinmultiple injection ornon-waler.supplywells
SUBMITTAL INSTRUCTIONS ;3r{j
ONLY with the same construction abandonment ym can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDkl: SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 55 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in IOa
6e.Borehole diameter: 4 (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: Unknown (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unknown (ft) IOc.For Water Suooly&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): Unknown (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016