Cumberland_Well Abandonment_20230915

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Borror I ' 1
7a.Number of welts being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non water supply rvelk ONLY with the same
construction/abandonment,you can submit'one form
4308-A + ' .
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 28
Billrs Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name lc.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable ivell construction permits(r.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: 1 lbs
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery,
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GrormdwaterRemediation 325lbs bentonite
[]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)
C- ,, ; ��--�F.-Measured depth of well and SWL
4.Date well(s)abandoned: 3-14-23 ti�. k 1 Li Disinfected well
5a.Well location: SEP 1 5 20b filled to top with bentonite
NC DOT
"tlrnr� '�V1rCt
Facility/Owner Name lain '' j 91 8.Certification:
NO ROAD yr t3T /( 3-14-23
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 1 SA 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:
(ifwe0 field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.982007 -79.042811 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 record(s)if available. For multiple injection or non-water supply
wells ONLY with the same constructlon/abatidonment,you can submit one form. 10a. For All Wells: Submit this'form within 30 days of completion of well
6a.Well k1111:
abandonment to the following: I
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 67 (fL) 1617 Mail Service Center,Raleigh,NC 27699-1617
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10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (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: 24 (ft) Division of Water Quality,C iderground Injection Control Program,
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): (ft.)
where abandoned.
f
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water)Quality Revised March 2013
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WELL ABANDONMENT RECORD For Internal Use ONLY: ( 1
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Borror 79.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-realer supply wells ONLY with the same
constructioWabandonnient,you can submit one form.
4308-A
7b.Approximate volume of water,remaining in well(s): 30 (gal.)
NC Well Contractor Certification Number
Blllis Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used:' 1 lbs
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check'all that apply):
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 12]Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑IndustriaVCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 325lbs bentonite
[]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)
�-- Measured depth of well and SWL
4.Date wells)abandoned: 3-14-23 4�� •�'ry ';� Disinfected well
So.Well location: SEP I ; 2�23 filled to top with bentonite
NC DOT t, ?sr.��:..9 ura
Facility/Owner Name acility ID�(�V'dpp'La3-b%7 S.Certification:
NO ROAD 3-14-23
Physical Address,City,and Zip Signafre of Certified Well Contractor or Well Owner Date
Cumberland By signing this form,I hereby certify that the well(s)was(1vere)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 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 diagram or additional well details:
34.981916 -79.042806 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 record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well EDP: abandonment to the following:
Division of Water Quality,Information Processing Unit,
1617 Mail Service'Center,Raleigh,NC 27699-1617
66.Total well depth: 66 (ft.) _
10b.For Injection Wells: In addition to sending the form to the address in 10a
4 above,also submit one copy of this form within 30 days of completion of well
tic.Borehole diameter: (in.) abandonment to the following: 1
21 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft•) 1636 Mail Servicel6nter,Raleigh,NC 27699-1636
1
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if(mown): 00 the address(es) above, also subinit 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): (fW where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of WaterlQuality Revised March 2013
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