Cumberland_Well Abandonment_20230915 (34)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
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Joshua Borfor 7a.Numberofwellsbeingabandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply tivelk ONLY with the same
4308-A construction/abandonment,you can submit one form.
7b.Approximate volume ofwater�remaining in well(s): 25.5 (gal-)
NC Well Contractor Certification Number
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.)ifknotivn 7d.Amount of disinfectant used: 1 Ibs
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check a:U 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: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 275lbs 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) ❑OtheAplai¢ud er 7")�r,
Y M- �-'. "--'�� Measured depth of well and SWL
4.Date well(s)abandoned: 3-14-23 SEP 15 Z023 Disinfected well
5a.Well location: lnforrarcn RrM 4 UrAfilled to top with bentonite
NC DOT DV,,-J'30G
ti tifi Cer caon:
Facility/Owner Name Facility ID#(if applicable) 8. 1
NO ROAD L .3-14-23
Physical Address,City,and Zip Signa of Certified Well Contractor or Well Owner Date
Cumberland By signing this form, I hereby certify that the ivell(q)ivas(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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/iong is sufficient) ' 9.Site diagram or additional well details:
34.970893 -79.018113 You may use the back of this page to provide additional well site details or well
N �l' abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach ivell construction records)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form. 109. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#•
abandonment to the following:
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Division of Water Quality,Information Processing Unit,
6b.Total well depth: 49 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection 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
6c.Borehole diameter: (in) abandonment to the following:
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10 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft-) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Infection 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
611 Inner casing/tubing length(if known): (fL) where abandoned. '
6g.Screen length(if known): (ft.)
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Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Qality Revised March 2013
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