Cumberland_Well Abandonment_20230915 (41)

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 11
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water; supply wells ONLY with the some
construction/abandonment,you can submit one form.
4308-A 5
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Bills 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.)##'known 7d.Amount of disinfectant used: 1/4 l bs
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) 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 ❑Groundwater Remediation 20lbS bentonite
OAquifer 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)
�,, ,.�,t �••--w•-, Measured depth of well and SWL
4.Date well(s)abandoned: 3-14-23 �, �t � :i. V Disinfected well
5a.Well location: SEP 5 2023 filled to top with bentonite
NC DOT
Facility/Owner Name ffl{�)'gcrP p;# If �U�b10) $•Certification:
NO ROAD V� 3-14-23
Physical Address,City,and Zip Signa a of Certified Well Contractor or Well Owner Date
Cumberland By signing this form, I hereby certfy that the well(s)was(were)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: i
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.964226 -79025713 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.
I
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)!f available. For multiple injection or non-water supply I.
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 IDii•
abandonment to the following:
'
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 14 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
2 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
11 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
i '
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (fL) 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
where abandoned.
6E Inner casing/tubing length(if known): (ft.)
I
6g.Screen length(if known): (ft.)
Form OW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013