Cumberland_Well Abandonment_20230915 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells k ;
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Sebastian Britt 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 wate4 remaining in well(s): 18 (gal.)
Blll's 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.)iflarown 7d.Amount of disinfectant used` 1 Ibs
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) laResidential 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 250 Ibs bentointe chips
❑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 Pulled pumping equipment
❑Geothermal(Heating/Cooling Return) OOther(explain under 7g)
-� s "Measured depth of well and SWL
4.Date well(s)abandoned: 3-8-23 Disinfected well
SEP 1 5, 1023
5a.Well location: Filled to top with bentorlite
T A LovingCompany
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
7730 King Rd, Fayetteville, NC 9L / 3-8-23
Physical Address,City,and Zip Si ature 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 15.4 NCAC 02C 10100 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:
34.9826789 N -79.0198329 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)if available. For multiple injection or non-water supply i
wells ONLY with the same constructionlabandonment,you can submit one form. 10a. For All Wells Submit this form within 30 days of completion of well
abandonment to the following: j
6a.Well ID#:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 45 (rc.) 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 tliisaform within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface:
18 Division of Water Quality,Underground Injection Control Program,
(ft)
1636 Mail Service Cent ter,Raleigh,NC 27699-1636
10c.For Water Supply&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (fG) the address(es) above, also submit Ione copy of this form within 30 days of.
completion of well abandonment'to}the county health department of the county
6f.Inner casing/tubing length(if known): (ft.) where abandoned. f
I ,
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013