Cumberland_Well Abandonment_20240731 (11)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor information: WELL ABANDONMENT 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 GW-30 is needed. Indicate TOTAL NUMBER of
2957-A wells abandoned:
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: yp
2.Well Construction Permit#:
Li.si all applicable well amsinrciion permit.+(i.e. 1/1C,(bury.Scare, Variance,eic.)t1'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(Heating/Cooling Supply) eResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a 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 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
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under 7 ) Poured concrete directly into well casing
and filled to within 3 feet of land surface and
4.Date wcll(s)abandoned: 7/9/24 installed 12-inch thick concrete cap on top.
5a.Well location:
NC DOT N/A
Facility/Owner Name Facility ID#(if applicable) 8•Certification: �/f
7406 Camden Road. "�, #ZQ:57- 7/10/24
Physical Address,City,and Zip Signature of Certified Well tontractor or Well Owner Date
Fayetteville, NC 28306 9494-54-5743 _
tic signing this(orm, 1 hereby cerlify that the �ekALw4, (sure)a1 t4n ir�
County Parcel Identification No.(PIN) accordance with 15A NC AC 02C.0100 or 2C.0200 Well Convlruction Slanc�crr
and that a copy gfthis record has been provided to the 1 ow�ter�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,)�'f� �7 _ 2024
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.971661 N 79.014917 W You may use the back of this page to providq ,UIC1ife'2!•tlW 4
abandonment details. You may also attach additional paga%Vid"
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attachwellconviructionrecord(s)ifavoilable. hitrmuiiipleinyecitonornon-u•aiersupplyu'elLc
ON1_Y with the some consiniciion abandonment,ynu can submit one irm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 50 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
IOb.For Iniection Wells: In addition to sending the form to the address in i Oa
6c.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 Supply&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
6E Inner casing/tubing length(if known,. Unknown (ft.) abandoned.
1.6g.Screen length(if known): Unknown (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016