Cumberland_Well Abandonment_20230915 (26)

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 abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) Far multiple injection or non-water supply tivel/s ONLY ivith the same
4308-A constrttclion/abandonmenr,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of wai er,remaining in well(s): (gal.)
Blll's Well Drilling Co. FOR WATER SUPPLY WELLSIONLY:
Company Name lc.Type of disinfectant used: ,HTH
2.Well Construction Permit#:
List all applicable ivell construction permits(i.e.County,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 IZI Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) laResidential 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 96lbs cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
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❑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)
C--; Measured depth of well and SWL
4.Date well(s)abandoned: 2-17-23 I K:Lf J.i
V Disinfected well
5a.Well location: SEP '2023 Filled to top with cement
T A Loving Company
InfAor'r' v„�_ r, . S.CertlfiCatlOni
Facility/Owner Name Facilt td)D (lffapp�bte
7332 Stoney Point, Fayetteville, NCB 2-17-23
Physical Address,City,and Zip Signa a of Certified Well Contractor or Well Owner Date
Cumberland By signing this form, I hereby certify that the ivell(s)ivas(were)abandoned in
County Parcel Identification No.(PIN) accordance ivith 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]at/long is sufficient) 9.Site diagram or additional well details:
34.987149 N -79.025573 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 i
wells ONLY with lire same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form 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: 20 (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:
i
6d.Water level below ground surface: (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Suonly&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
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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
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WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i
t :
1.Well Contractor Inf6rmation: WELL ABANDONMENT DETAILS
Joshua Borror 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple infection or non-ivater supply wells ONLY ivith the some
constructionlabandonment,you can submit one form.
4308-A f
NC Well Contractor Certification Number 7b.Approximate volume of wate.remaining in well(s): 1'3 (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)ijknorvn 7d.Amount of disinfectant used 1/4 Ibs
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout El 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 75 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:
❑Geotherrmal(Closed Loop) ❑Tracer
❑Geothermal Heating/Cooling Return) ❑Other(explain under 7g)
Measured depth of well and SWL
4.Datewell(s)abandoned: S��.r"QP �; E-I Disinfected well i
5a.Well location: SEP 15 2023 Filled to top with bentonite
T A Loving Company
Facility/Owner Name $•Certification:
7314 Stone Point Rd, Fa etteville, „"��`�
Y Y ��``J` 2-17-23
Physical Address,City,and Zip Si lure of Certified Well Contractor or Well Owner Date
Cumberland By signing this form, I 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 Constniction 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 fat/long is sufficient) 9.Site diagram or additional well details:
34.986928 N -79.025192 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 infection or non-water supply
wells ONLY ivith the same construction/abandonnient,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 EN:
�I
Division of Water Quality,Information Processing Unit,
6b.Total well depth. 31 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection 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:
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6d.Water level below ground surface: 10 —(ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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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 lone copy of this foam 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.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013