Cumberland_Well Abandonment_20240918

WELL ABANDONMENT RECORD For Internal use ONLY:
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1.Well Contractor information: WF,LL ABANDONMENT DETAILS
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I<. Brandon iVI00Pe 7a.For Geoprobe/DPT or Closed'Lgop 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
•2957—A wells abandoned: p
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#:
Lis�all applirahle a ell consmrciion permi�s(i.e.1/1C•,C•oanly,Slate,Variance,etc•.)ifknown 16 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) 9Residential Water Supply(single) ❑ Sand Cement Gr _ p-D!�,Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 19 Concrete Grout ,,,�,•..�,:; ;r'�7wD ill uttings
❑Irrigation ❑ Specialty Grout _ ❑Gravel
Non-Water Supply Well: El Bentonite Slurry S E P '1 8 2021 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f:For each matt=r!5r9crdeiedta1?6�.d,4)4idt bn)Snt of materials used:
❑Aquifer Recharge ❑Groundwater Remediation COrlCrete gPOUt l�rTiGa'i3t. 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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Poured concrete directly into well casing
and filled to within 3 feet of land surface and
d.Date well(s)abandoned: 9/10/24 installed 18-inch thick concrete cap on top.
5a.Well location:
NC DOT N/A
Facility/Owner Name - Facility ID9(if applicable) 8.Certification:
6145 Camden Road j�-� ✓' Q Z 957- 9/11/24
Physical Address,City;and Zip Signature of Certified Well Contractor of Well Owner Date
Fayetteville, NC 28306 0404-56-4978
By signing this form, 1 hereby ceg7 fy that the well(s) was (were) abandoned in
County Parcel identification No.(PIN)• accordance with ISA NCAC 02C.0100 or 2C.0200 Well 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: F
(ifwel]field,one laUlong is sufficient) 9.Site diagram or additional wellydetails:
34.978392 N 79.981754 W You may use the back of this page to provide additional well site details or well
j abandonment details. You may also
attach additional pages if necessary.
(nNST13]ICTin D�FT4iLS OF WEJJi(_SJREJ1LG7BAND.aNED
Altochive0consinic•lionrccord(r)ifaiailahle.l•iormidtip/cinjeclionornon-u•ater.wipp/),u,ellc y Y'7vu�"ri:.a:';w �r.-a��dii,.�.- -"' ••
ONLY wish the same conriniciion ahandaunrew.Yon can snbmir one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well iD#: SW-1 abandonment to the following:
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Division of Water Resources,Information Processing Unit,
6b.Total well depth: 50 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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6d.Water level below ground surface: Unknown (ft) Division of Water Resources,lUnderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Unknown 10c.For Water Sunoly&Iniection Wells: In addition to sending the form tothe
6e.Outer casing length(if known): (ft.) 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 G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016