Cumberland_Well Abandonment_20230915 (8)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i.
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jonathan Kamionka 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or nondwater supply wells ONLY with the same
constructioWabandonment,you can submit one form.
3465-A
NC Well Contractor Certification Number 7b.Approximate volume of watt r remaining in well(s): 60 (gal.)
Blll's Well Drilling Co. FOR WATER SUPPLY WELL'S 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.)ifknown ]d.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 0 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
❑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 ❑Groundwater Remediation 450 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 pump
❑Geothermal(Heating/Coohng Return) ❑Other(explain under 7g)
s c--�?-•• F � �„� Measured depth of well and SWL
— �a.
4.Date wells 3-14-23 Disinfected well abandoned: '
5a.Well location: SEP 1 2023 filled to top with benonite
T A Loving Company 1 „ ;i n �-;,: � Ur
Facility/Owner Name Facility ID Wplrcw.affc) 8.Certification:
Z/,
7127 Stoney Point Rd, Fayetteville, NCLA"", 3-14-23
Physical Address,City,and Zip Si lure of Certified Well tontractoi 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:
(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 ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit t11is,fort 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: 79 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
i
10b.For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one co of this form within 30 days of completion of well
6c.Borehole diameter: 4 (in.) copy y p
abandonment to the following:
I
6d.Water level below ground surface: 18 (ft.) Division of Water Quality,Uriderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Intel lion 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 fort within 30 days of
completion of well abandonment to the county health department of the county
6L Inner casing/tubing length(if known): (ft.)
where abandoned.
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