Cumberland_Well Abandonment_20230915 (19)

WELL ABANDONMENT RECORD ForinternalUseONLY:
This form can be used for single or multiple wells 14
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Borror 7a.Number ofwells 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
4308-A construction/abandomnent,you can submit,one fornt.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 7
I I (gal.)
Blllhs 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.)ifkaown 7d.Amount of disinfectant used, 1 I bs
i
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) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
0Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry i. ❑Other(explain under 7g)
[]Monitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 200 lbs ' bentonite chips
❑Aquifer Storage and Recovery ❑Salinity Barrier
i
❑Aquifer Test ❑Stormwater Drainage
i
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pulled pump from well
[]Geothermal(Heating(Cooling Return) ❑Other(explain under 7g)
[--��„ Measured depth of well and SWL
a.Date well(s)abandoned: 5-31-22 k ti'� r " "� Disinfected well
�+�rp
5a.Well location: JCr 1 5 2023 filled with bentonite chips
TA Loving Company
lt�•�-.'7.i�w�i„�.1�L•I r�f:�rs�i"J.i r� o
Facility/Owner Name Facility IEW If jWTcgiG S.Certification:
2116 Bedloe St., Fayetteville, NC 28304 1 :_i 5-31-22
Physical Address,City,and Zip Signatur of Certified Well Contractor or Well Owner Date
Cumberland By signing this fonn,1 hereby certify that the ivell(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 fat/long is sufficient) 9.Site diagram or additional well details:
35.023348 -79.025790 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 nmltiple injection or non-water supply
wells ONLY with the same constntctim✓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,
66.Total well depth: (ft.)
33 1617 Mail Service Center,Raleigh,NC 27699-1617
i
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: $ (in.) above,also submit one copy of thisform within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface:
18 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Suooly&Infection Wells: In addition to sending the form to
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 Innercasing/tubing length(if known): 33 where abandoned.
f '
6g.Screen length(if known): 6 (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
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1
WELL ABANDONMENT RECORD ForintemalUseONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Borror C
7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or nonlivaler supply wells ONLY with the sate
constructiot✓abandonment,you can submit one form.
4308-A
NC Well Contractor Certification Number
7b.Approximate volume of wat fr remaining in well(s): 210 (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(1.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: 2 lbs
i
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) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
ElIrri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: El Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 600 Ibs bentonite slurry
❑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 Pulled pump from well
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
.�" �
Measured depth of well and SWL
,�, .! -„"��3
4.Date wells)abandoned: 5-31-22 � �, ifr �i V Disinfected well
5a.Well location: SEP 1 55 2023 pumped full of bentonite slurry
TA Loving Company
Facility/Owner Name I< FS>at3`1I33#2r tt a��fp?b7- ~"X "fN•Certification:
2109 Pinewood Terrace, Fayetteville,Iff "'7 NO 5-31-22
Physical Address,City,and Zip Signature qfCerfified Well Contractor or Well Owner Date
Cumberland By signing this forni, 1 hereby certify that the ivell(s) was(svere)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:
35.024219 -79.022226 You may use the back of this page to provide additional well site details or well
Nr W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS 1
Attach well construction record(s)if available. For multiple injection or non-water supply
ivells ONLY with the sane construction/abandonment,you can submit one fort. 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: 340 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
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:
200 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to
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): 251 (ft.) where abandoned. �
i
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water t2uality Revised March 2013
t

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WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I`
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Sebastian Britt 7a.Number ofwells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-uvaler supply wells ONLY with the saute
4567-C constructionlabandonment,you can submit one form.
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number I
Blllrs Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: ;HTH
I.
2.Well Construction Permit#:
List all applicable well construction permits(1.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: 1 cup
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural OMunicipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential 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: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation cement 45lbs
❑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) Cl er4explain nder 7g
r--i V r--L; Measured depth of well and SWL
4.Date wells)abandoned: 7-28-22 i.
SELP 1 Fi 2023 Disinfected well
5a.Well location: filled to top with cement
Deanna Chavis } '' Ur'
Facility/Owner Name Facility 1D#(ifapplicable) 8.Certification:
2786 Baywood Rd, Eastover, NC 28312 a 7-28-22
Physical Address,City,and Zip Signature of Certified Well Contractorlor Well Owner Date
Cumberland By signing this form, I hereby certify that the ivell(s)ivas(1vere)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 hasibeen 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 records)if available. For multiple injection or non-hater supply
wells ONLY with the same consiructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID#-
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 23 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
1 Q 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&Injection Wells: In addition to sending the form to
6e.Outer rasing 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 easing/tubing length(if known): (fL) where abandoned.
i
6g.Screen length(if known): (ft.) i
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
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