Cumberland_Well Abandonment_20230915 (12)

WELL ABANDONMENT RECORD For Internal Use ONLY
This form can be used for single or multiple wells
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jonathan Kamionka t 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.
3465-A
NC Well Contractor Certification Number 7b.Approximate volume of water'emaining in well(s): 40 (gal.)
Bill's Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name TH
7c.Type of disinfectant used: i
2.Well Construction Permit-#: !'
List all applicable well constnuction permits(i.e.Coun)4 State,variance,etc.)ifknown 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 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑ Sand Cement Grout ! ❑ Dry Clay
❑lndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
Olrri 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 350lbs '. bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier I
❑Aquifer Test OStormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of-the abandonment procedure:
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❑Geothermal(Closed Loop) ❑Tracer removed pump
❑Geothermal(Heating/Cooling Return). ❑Other(explain under 7
e... Measured depth of well and SWL
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3-14-23 V IL�
4.Date well(s)abandoned: c C P 15
2023 Disinfected-well
5a.Well location: J C filled to top with bentonite
T A Loving Company Inv. n��'" Ual
Facility/Owner Name Facility IDff(if applicable) 8•Certification:
7143 Stoney Point Rd, Fayetteville, NC 3-14-23
Physical Address,City,and Zip SigniAffe of Certified W .Contractor,or Well Owner Date
Cumberland By signing this form, I hereby certtfy that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02G`.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:.. h
(if well field,one Iattlong 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 construclion/abandonment,you can submit oneform. 10a. For All Wells: Submit this'fomr within 30.days of.completion of well
abandonment to the following:
6a.Well ID#: t: .
Division of Water Quality,'Information Processing Unit,
6b.Total well depth: 61 (ft,) 1617 Mail Service,Center,Raleigh,NC 27699-1617
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10b.For Iniection Wells: In addition to sending the form to the address in 10a
4 above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
C '
6d.Water level below ground surface 28 (ft) Division of Water Quality,lUnderground Injection Control Program,
1636 Mail ServicekCenter,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection 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
6E Inner casing/tubing length(if known): (ft.) where abandoned. ( '
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6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water�Quality Revised March 2013