Cumberland_Well Abandonment_20230915 (16)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
I
Joshua Borror 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 Ewdter supply wells ONLY with the same
constructionlabandonment,you can submit one form.
4308-A 1. 40
NC Well Contractor Certification Number I
76.Approximate volume of water remaining in well(s): (gal.)
Bills 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.(7ounty,State,Variance,etc.)i(known 7d.Amount of disinfectant used 1 Ibs
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all thatapply):
❑Agricultural ❑Municipal/Public ❑Neaf Cement Grout El Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) EIResidential 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 ❑GroundwaterRemediation 480lbs j. bentonite
❑Aquifer Storage and Recovery El Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer removed pump
❑Geothermal(Heating/Cooling Return) 0QAeaqXp in under 7g)
t:L;I,-{V� Measured depth of well and SWL
a.Date well(s)abandoned: 3-14-23 SEP 1 5 .2023 Disinfected well
5a.Well location: filled to top with bentonite
T A Loving Company +'s€`">,�'MAI
Facility/Owner Name Facility IDh(if applicable) 8•Certification:
7155 Stoney Point Rd, Fayetteville, NC 3-14-23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Cumberland
By signing this form,I hereby certiYy that the wells) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A 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 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 ONLYwith the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit thi s 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: 60 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
11
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
6e.Borehole diameter: (in.) abandonment to the following:
20 Division of Water Quality,Underground Injection Control.Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniec*on 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 abandonmentf to;the county health department of the county
6E Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised_ March 2013