Cumberland_Well Abandonment_20230915 (22)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Sebastian Britt 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or Inon-water supply wells ONLY with the same
construction/abandonment,you can submit one form.
4567-C
NC Well Contractor Certification Number 7b.Approximate volume of'ater remaining in well(s): 22
Blll's Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name lc.Type of disinfectant used: HTH
i
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)iflmown 7d.Amount of disinfectant used: 1 Ibs
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout El Bentonite Chips or Pellets
i
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industriat/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 250lbs 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
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
_ Measured depth of well and SWL
4.Date well(s)abandoned: 8-26-22 q' �I. + E Disinfected well
5a.Well location: SEP 15 2023 Filled to top with bentonite
TA Loving c.�..,Ty
Irtf a.Certification:
Facility/Owner Name ;;acrhty'f t( u ff1D;4Ie)
7109 Stoney Point Rd, Fayetteville, NC xd,., &-;6p-- 8-26-22
Physical Address,City,and Zip Signature of Certified Well Contractor 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 ivith 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell 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:
34.981812 -79.017018 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 this form within 30 days of completion of well
6a.Well TD#:
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 Injection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
17 Division of Water Quality;Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
loc.For Water Supply&Injection 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
I
6E Inner casing/tubing length(if known): where abandoned.
(ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Watel Quality Revised March 2013

i
WELL ABANDONMENT RECORD
For Internal Use ONLY: i
This form can be used for single or multiple wells II`
1.Well Contractor Information: WELL ABANDONMENT DETAILS]
Sebastian Britt 7a.Number of wells being abando jedi: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply ivells ONLY with lire same
4567-C cmnstruclionlabanndonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of water lemaining in well(s): 26 (gal.)
Blll's Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit#: i
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknow't 1 I bs
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check ali that apply):
❑Agricultural ❑MunicipaVPublic ❑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: 7E For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 500lbs bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
i
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description oft abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer pulled pump from well
❑Geothermal(Heating/Cooling Return) ❑Other(e lftirnndei57g}_,,
c LZ k, a Measured.depth of well;and SWL
a.Date well(s)abandoned: 11-2-22 SEP 1 5 2023 Disinfected well
5a.Well location: filled to top with bentonite
Abel Ayala lnt�t�cs n��` �E.rt
13t3°t,rn,�.
Facility/Owner Name Facility 1D#(if applicable) g•Certification:
3796 Gateway Dr, Fayetteville, NC 28306 11-2-22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Cumberland 0424-85-7001 By signing this form, I hereby certify that the ivell(s) ryas(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 toyprovide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
i
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple h jection or non-water supply
wells ONLY with the some construction/abandonment,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: 85 (fb) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in•) abandonment to the following:
41 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&Infection 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): 70
where abandoned.
6g.Screen length(if known): 15 (ft.)
I
Form GW-30 North Carolina Department of Environmentand Natural Resources—Division of Water Quality Revised March 2013

i
I
WELL ABANDONMENT RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Borror 7a.Number of wells being aba Idoued: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non°-ivater supply wells ONLY ivith the same
construction/abandonment,you can st}bmlt one form.
4308-A f I
7b.Approximate volume of water'remaining in well(s): 30 (gal.NC Well Contractor Certification Number I I )
Blll's Well Drilling Co. FOR WATER SUPPLY WELTS ONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit M I
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 ❑MunicipaUPublic ❑Neat Cement Grout El Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) EIResidentiat Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 350 Ibs bentonite chips
❑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) ❑Other explain under 7g)--,r:4,
, ` _
�r� V _ L/ Measured depth of well and SWL a.Date well(s)abandoned: 2-17-23 _P r, 2023 Disinfected well
I.
Sa.Well location: Ursa Filled to top with bentonite
T A Loving Company Fr ,- {n,si wa.a�
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
3213 Mesquite Dr, Fayetteville, NC 2-17-22
Dire
Physical Address,City,and Zip Sifnatuw ofCertified Well Contractor or Well Owner Date
Cumberland By signing this form, I hereby certify that the well(,) teas(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.
Sb.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:
34.982788 N -79.020321 W You may use the back of this page to provide additional well site details or well
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 ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this fonn within 30 days of completion of well
6a.Well IDII•
abandonment to the following:
,
Division of Water Quality,Information Processing Unit,
6b.Total well depth. 66 (B) 1617 Mail Service Center,Raleigh,NC 27699-1617
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 this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 20 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
l0c.For Water Supply&Iniecti J n 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
where abandoned.
6E Inner casing/tubing length(if known): (ft.) I
i
6g.Screen length(if known): (tt.) !
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
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