Cumberland_Well Abandonment_20240903 (2)

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#:
List all applicable hell cunsirucriun permits(re I/V.r ouniv,Stare,Variance,eic.)it known 8 oz.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ItlResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑lndustrial!Commercial ❑Residential Water Supply(shared) N 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 1.5 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 7g)
and filled to within 3 feet of land surface and
4.Date well(s)abandoned: 8/27/24 installed 12-in"ch thick concrete cap on top.
5a.Well location:
NC DOT N/A ,I
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
6814 Camden Road I t`FS-1=4 8/27/24
Physical.Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Fayetteville, NC 28306 0404-06-6101 y y ty (j
B signingthis urm, 1 hereby ce7i' that the wells was were abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Consrniclion Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy gf'this record has been provided to the well owner.
(ifwell field,one hit/long is sufficient) 9.Site diagram or additional well details:
34.976040 79.998039 M. 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 SUBMITTAL INSTRUCTIONS
Anach ire/l consinic•lion record(s)if available. l•br nmlriple injeclion or non-vater.snpplt irells
ONLY with the same comrniction abandonment,you can.submit one firm.
10a. For .411 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: 66 (ft.) 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
lob.For Infection Wells: In addition to sending the form to the address in 10a
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.) 10c.For Water Sunoly&Infection 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
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016