Cumberland_Well Abandonment_20230109

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i•
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lawrence D. Opper 7a.Number of wells being abandoned I 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water I' supply wells ONLY with the same
_ construction/abandonment,you can submitionl form.
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NC 3322-A yam.. t�aa�
'.�.: ( "o FEE 91 �� �" 7b.Approximate volume of water remaining in well(s): � (gal.)
NC Well Contractor Certification Number P i
Regional Probing Services JAy 0 9 Z923 FOR WATER SUPPLY WELLS ONLY:
Company Name
ng Li"i:l 7c.Type of disinfectant used:
2.Well Construction Permit
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑IndustrialUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 65lbs
❑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 Filled/hydrated from bottom-up. Capped with concrete.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 11/29/2022
Sa.Well location:
Coliseum Family Fare BP#185
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
2036 Gilespie Street, Fayetteville Lawrence Opp erar 12/13/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Cumberland By signing this form, 1 hereby certify that the ivell(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided io the well owner.
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:
35.020875 78895768 You may use the back of this page to provide additional well site details or well
.
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)if available. For multiple injection or non-water supply
wells ONLY with the same constructionlabandonment,you can submit one form. — 10a. For All Wells: .Submit this form within 30 days of completion of well
6a.Well ID#: MW-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 35 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
well dia: 2 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
approx 30 Division of water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
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10c. For Water Supply&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
6E Inner casing/tubing length(if known): 15 (ft.) where abandoned.
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6g.Screen length(if known): (ft.)
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Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013
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