Cumberland_Well Abandonment_20220729

P
I�
t
WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well ontractor Infor lion: WELL ABANDONMENT DETAILS
61 L6—�_ S201 7a.Number of wells being abandonned:
Well Contractor Name r well owner personally abandoning well on his/her property) For mulaple injection or non water supply wells ONLY with the some
consrructionlabandonment,you can subnilt oneform.
3 7b.Approximate volume of water,remaining in well(s): �� (gal.)
KNWelyoni or Certification&NNb GN�1/Ct; FOR WATER SUPPLY WELLS LY:
Company Name 7c.Type of disinfectant used: 't
2.Well Construction Permit#:
List all applicable well permits(i.e.Coimo%State,tfarianee,Injection,etc:)if known 7d.Amount of disinfectant used: CC/
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
[]Munici aVPublic []Neat Cement Grout Bentonite Chips or Pellets
OAgricultural P
(single)
�[]Sand Cement Grout []Dry Clay
[]Geothermal(Heating/Cooling Supply) Residential Water Supply ,( ❑ Drill Cuttings
01ndustrial/Commercial ❑Residential Water Supply(shared) ►'!l Concrete Grout P>s
[] Specialty Grout O Gravel
DIrrigation e Other )
(explain under 7
__NonmWater Supply Well: ❑ Bentonite Slurry [] ( .P g
ORecove
❑Monitonng ry. F
Injection Well. 7f./ r each m aerial selected above,provide/amount of materials used:
[]Aquifer Recharge OGroundwaterRemediation /7 `�DG�gf 61n/ply�(;Etr
[]Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test oStorinwater Drainage
[]Experimental Technology []Subsidence Control 7g.Provide a brief ascription of the abandonment procedure:
[]Geothermal(Closed Loop) []Tracer rOVr p� � pt�/'e (/l r S jri to -1u"e. Wittx 7rZ e-
[]Geothertnal(Heatin Coolin Return). .. []Other(explain,under 7g) '
cAgf (/et i in t t/etrv4
4.Date well(s)abandoned: d Nl , r rd i=ffiiedWell
,lvC a Ie t it. Z t 0 rtl /oft;/
52.Well location: . j,4/Facility/Owner Name Facility ID#(if applicable)�&0TC�1LLD.r �,�tfd�iE A4L 8aPhysi Add City,said Zip Owner Date
By signing this form,I hereby certify that the well(
•) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I SA NCAC 02C.0100 or 2C.0200 WeU 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: 9.Site diagram or,additional welhdetails;
(if well field,one lat/long is sufficient)
�8 A� N V-7 nt D,`fo�� You may use the back of this page'to provide additional well site details or well
3 qa
f 7 '� W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if avallable: For.,nulilple injection or non-water,supply
wells ONLY with the same roniiructlorilabandonment,you can submit onefonn• 16a. For.All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
69.Well ID#:
Division of Water Resources,Information Processing Unit,
l 1617 Mail Service Center,Raleigh,NC 27699.1617
6b.Total well depth:
10b:For Infection Wells: In addition to sending the form to the address in 108
above,also submit one copy of this;form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
1
3�(tt., Division of Water Resources Underground Injection Control Program,
6d.Water level below ground surface: 1636 Mail Service Center,Raleigh,NC 27699.1636
V h��n 0 W� - ft. 10c.For Water Sunnly A Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): ( ) the address(es) above, also submit'one copy of this form within 30 days of
completion of well abandonment to the E-oUdM* eMt j �r)t,gf e county
where abandoned. a �•
6E Inner casing/tubing length(if known):
JUL 2 9 2022
6g.Screen length(if known): (ft.) i Witomation Procaaomg Unk
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013