Cumberland_Well Abandonment_20230428

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Fy r l�- 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 G W-30 is needed. Indicate TOTAL NUMBER of
3)-���� /) wells abandoned: C�
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): ° v (gal.)
1-f-C a Yyl FOR WATER SUPPLY WELLS ONLY:
Company Name
N 2 � 7c.Type of disinfectant used:
.Well Construction Permit#:
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc.)if kin rm
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 m�'°h ^' •y entso to Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout Y �' [�`i tEl •Fyl dd
❑Industrial/Cornmercial ❑Residential Water Supply(shared) ❑Concrete Grout A P R 2 S 2 nll Cuttings
❑Irri ation ❑ Specialty Grout Cf vel
Non-Water Supply Well: ❑Bcntonite Slurry Int0fMaa on Pf:,eC*&1;3s7iV y-,%xplain under 7g)
onitoring ❑Recovery D1OOOG
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Q `75 165 0 &cn l idv P--T — LL r•
❑Aquifer Storage and Recovery ❑Salinity Barrier ( r 5 ''F—
n �
❑Aquifer Test ❑Stormwater Drainage - 1
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ,rye
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
tr
2 (�el !
4.Date well(s)abandoned: ✓ ' �QV6h��j� el_;A� �• add VA Lt l-QJ U VL�t l
Sa.Well location: oLj- Ste!!-Q t�. O er
P VJ Cf,'Lr'>_
Facili /Owner Name Facility[DO(if applicable) 8.Ce Ica on: nn
IN - 1-1 4--ok P-
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CINr►.bvrl G of ©t{ 1- 1 - 3109
By signing this jonn,I hereby certify that the well(v) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
$- q a'���3 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
Attach well construction record(s)ifavailable.Formrdtiple injection ornon-watersupply wells
ONLY with the same constn4clioulabandonment,your can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• M abandonment to the following:
3 t Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I 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,
�1 1636 Mail Service Center,Raleigh,NC 276994636
/1 Y`1 10c.For Water Suuoly&Injection Wells: In addition to sending the form to the
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
6E Inner casing/tubing length(if known): a 0 (ft.) abandoned.
6g.Screen length(if known): ' " (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Rcsourc Is Revised 2-22-2016

Photo of MW-12 Pre-abandonment
Photo of MW-12-Post-abandonment

WELL ABADONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
D.T. Chalmers,JR 7a.Number ofwells being abandoned: N/A Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection ornon-+rater supply a-elis ONLY with the same
constntction/abandonmem,you can submit one form. -
4146A
NC Well Contractor Certification Nwnber 7b.Approximate volume of water remaining in well(s): N/A (gal.)
CATLIN:Engineers and Scientists : FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable+rellpermits(i.e.County,State;Yariauce,-Gjec(iotm,eic.)ifkno+rn 7d.Amount Of disinfectant used: NIA
3.Well use(checkwell use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ®Bentonite Chips or-Pellets.
O Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay .
❑IndustriaVCommercial. ❑Residential Water Supply(shared). ❑Concrete Grout " ❑Drill Cuttings
❑Irrigation .rN �1 '.0gecialty Grout ❑Gravel
Non-Water Supply Well: "Ergentonite Slurry ❑Other(explain under 7g).
■Monitoring ❑Recovery. 9, .9
Injection Well: : 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge 0Ground!AruxAsT,91§(im{n; r Bentonite Pellets -100 Ibs Ibs.
El Aquifer Storage and Recovery El Salinity Barrier. Ctr3
❑Aquifer Test. ❑Stomiwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer' 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Well cut off to approximate 6 inches below existing
grade and remainder of well abandoned in place
4.Date well(sj abandoned: 4/6/2023 with hydrated berltonite pellets to existing -grade.
5a.Well Location:
.....
SGC Towers-Bonnie Doone N/A
Facility/Owner Name Facility ID#(if applicable) Certification: l 8. n:
Park Lane Circle, FAYETTEVILLE,28303 AAnd:10.2023 .
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date.
CUMBERLAN D- N/A By signing this fonn I hereby certt&that the ivell(s)ivas(here)abandoned in
County Patcel Identification No.(PIN) accordance ivith75A NCAC 02C.0100 or 2C TVell.Constrtretion Standards and.
that a:copy of this r ecor d has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or-decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagrain.or additional well details: .
35.099201 78.950668 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable..For multiple injection or non-water supply
well ONLYtvid+the same conviruclion abandonment,you cati smtbiriit oneform 10a.For All Wells: Subnut this form within 30 days of completion of well
et
6a.Well ID#: B-01. abandonment to the following:
Division of Water Resources,Information Processing Unit,' .
6b.Total well depth: 65 (ft.) .1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in
6c..Borehole diameter: 8.25(in.) 10a 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: NM(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A 10c.For.Water Supply&Iniection 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
6G Inner casing/tubing length(if known): 65(ft.) county where abandoned.
6g.Screen length(if known):. N/A(ft.)
S:\GINIVROJECPS\223036-130NNIE DOONE_FAYETTEVILLE,NC.GPJ
Adapted from NCDENR-DWR:Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources _ Revised August 20.13_