Cumberland_Well Abandonment_20230915 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Sebastian Britt I 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-water supply wells ONLY with the same
construction/abandonment,you can submit one form.
4567-C
NC Well Contractor Certification Number 7b.Approximate volume of w I ter remaining in well(s): 3 (gal.)
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Bills Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name !'HTH
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifhmwn 7d.Amount of disinfectant used: 1 cup
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) OResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 350 Ibs 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 removed equipment
❑Geothermal(Heating/Cooling Return) ❑ e' larrl!un�err 7�)�-
"` Measured depth of well and SWL
4.Date well(s)abandoned: 8-28-23 SEP 1 K 2023 Disinfected well i.
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5a.Well location: 1n5. ::� .n ?���� u�# filled to top with beritonite
NC DOT
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
3510 Golfview Rd, Hope Mills, NC 28348 8-28-23
Physical Address,City,and Zip Signature of Certified Well Contrac or or Well Owner Date
Cumberland By signing this form, 1 hereby;certify 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
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 I
wells ONLYwith 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 ID#:
abandonment to the following:
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Division of water quality,Information Processing Unit,
6b.Total well depth: 57 (ft.)
1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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
6e.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface 41 (ft•) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (fb) 10c.For Water Sunoly&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 county
6E Inner casing/tubing length(if known): (ft.) where abandoned.
P
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013