Cumberland_Well Abandonment_20230915 (13)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jonathan Kamionka
7a.Number of wells being abandoned: 1
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
3465-A construction/abandonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 30 (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.)iflmown Jd.Amount of disinfectant used: '1 Ibs
3.Well use(check well use):
i
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 21 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: 7C 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 pump 1
[]Geothermal(Heating(Cooling Return) ❑Other(explain under 7g) '
1.-�� Measured depth of well and SWL
1 ,d
4.Date well(s)abandoned: 3-14-23 S E P 1 5% •2023 Disinfected well
5a.Well location: filled to top with bentonite
T A Loving Company InL-fii^n Pr:rw t:.w
Facility/Owner Name Facility ID#(if applicable) 8•Certification-
Facility
Stoney Point Rd, Fayetteville, NC LA TZ, 3-14-23
Physical Address,City,and Zip Signat of Certified Well Contractor or Well Owner Date
Cumberland By signing this form, I hereby certify that the wells) 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 WELLS)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: 50 (ft.) 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 this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
I,
6d.Water level below ground surface: 19 Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I, .
10c.For Water Supply&Infection Wells: In addition to sending the form to
6e.Outer casiug length(if known): (ft.) the address(es) above, also subrhit'one copy of this form within 30 days of
completion of well abandonmentjI to the county health department of the county
where abandoned.
6E Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
1 .