Cumberland_Well Abandonment_20230915 (6)

WELL ABANDONMENT RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells i r
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Borror 7a.Number ofwells being abaldoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or nor-water supply wells ONLY with the same
4308-A construction/abondonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of wate r'remaining in well(s): '25 (gal.)
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Blll's Well Drilling Co. FOR WATER SUPPLY WELLSIONLY:
Company Name 7c.Type of disinfectant used: Hl-H
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2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifl mown 7d.Amount of disinfectant used: 1/4 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) OResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout 1 ❑ 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 20lbs bentointe.
❑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) ❑Other(explain under 7g)
Measured depth of well and SWL
4.Date well(s)abandoned: 3-14-23R ce' a i ""F
,,, �. 0 ,�, Disinfected well ,.
5a'Well location: SEP 1 ; 2023 filled to top with bentonite
T A Loving Company
Facility/Owner Name IR C frlyID-'1/' v r� � rR $•Certification:
5180 Lakewood Dr, Fayetteville, NC � 3-14-23
Physical Address,City,and Zip Signatu 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 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:
(ifwell 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
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 ID#:
abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 8 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection 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:
6d.Water level below ground surface 7 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service iCenter,Raleigh,NC 27699-1636
10c.For Water Sunoly&Iniechou 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
6f.Inner casing/tubing length(if known): (ft.) where abandoned. i
6g.Screen length(if known): (ft.)
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Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
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