Cumberland_Well Abandonment_20230915 (11)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Borror 1 ' 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-iv supply wells 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): 20 (gal.)
Blllrs 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.)tfknown 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 El Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 211kesidential 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 ❑GroundwaterRemediation 275-Ibs bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description ot;the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal Heating/Cooling Return) ❑Other(explain under 7g)
' R Measured depth of well`and SWL
4.Date well(s)abandoned: 3-14-23 ra.=c _ k- t, Disinfected well
5a.Well location: SEP 1 1 2023 . filled to top with bentonite
NC DOT
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Facility/Owner Name Facility ID�°i�e�pT�ieA6te 8.Certification: i
NO ROAD 3-14-23
Physical Address,City,and Zip Signoire of Certified Well Contractor or Well Owner Date
Cumberland
By signing this form, I hereby certify that the well(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: i
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.981931 -79.043174 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
abandonment to the following:
6a.Well ID#:
Division of Water Quality,Information Processing Unit,
66.Total well depth: 51 (g) 1617 Mail Service Center,Raleigh,NC 27699-1617
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:
20 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&Iniectiou Wells: In addition to sending the form to
6e.Outer casing length(if known): (M) 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): (%)
where abandoned.
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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