Cumberland_Well Abandonment_20230327 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: tiVELL ABANDONMENT DETAILS
f7tr a n k. ?f-� � 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the saute
Well Contractor Name(or well owner personaliy abandoning well on his/her property) well construction/depth,only 1 OW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1 . 0(0 (gal.)
Jq e,C,0 r"1 FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
i
2.Well Construction Permit#:
List all applicable aril construction pernits(i.e.UIC.County,State,Ybriancc,etc.)if/monn
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) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water-Supply(shared)s -JO.Concrete Grout ❑Drill Cuttings
❑Irrigation s V i.(79S,pecialtyGrout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
onitoring ❑Recovery MAR 2 7 202
njection Well: 7f.For each material selected above,,provide amount of materials used:
❑Aquifer Recharge ❑GroundWWf R&Wriat;q�tf;m 'f 3 i3 '�bs O� J1 O�/7•�tJv�� ��>I1r,ZJ�-
❑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 a t 1
❑Geothennal(Heating/Cooling Return) ❑Other(explain under 7g) r L,,
qq 2 M 70 1 d v `&, —sk Lw"L��T W t ,A W cMk
4.Date well(s)abandoned: * /1 irdy1,t� vi�
5a.Well location:
$04 rr wa`1 (��SS f►J f�
Facility/Owner Name I Facility ID#(if applicable) S.Certification:L4 -�D &r u v,L St-. n�o►�L�e vi��t �tNC, ��3c�( -�.,,,Qti �c•"r-- a, t-), 3-3
Physical Address,City,and Zip Signature of Ccrdfred Well Contractor or Well Owner Date
Cj, )V-w\,&v-A ® y31• q' •S N 3S
By signing[his Jornt, I hereby certify Mal 1/re ive!/(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with iSA NCAC 02C:0100 or 2C.0200 lVe/1 Construction Standards•
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude indegreeslntiuutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35"• S 3 N - , W 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
Attacdiwellcorstrtrctionrecord(s)ifaiwilable- For multiple inhjectionornon-watersupplywells
ONLY with the same con ctructio ul, a_do h h�ntlu,you can submit one form.t.il 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well iD#• abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: t (ft) 1617 Afail Service Center,Raleigh,NC 276994617
S 10b.For injection Wells: in addition to sending the form to the address in 10a
�+`6c.Borehole diameter: (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 (ft.) Division of Water Resources,Underground injection Control Program,
1636 Afail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
r of well abandonment to the county health department of the county where
6E inner casing/tubing length(if known): (ft.) abandoned.
f
6g.Screen length(if known): ` (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016