Cumberland_Well Abandonment_20230915 (28)

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 non iwgter supply wells ONLY with the same
construction/abandonment,you can submit one form.
4567-C
7b.Approximate volume of water remaining in well(s): 33 (gal.)
NC Well Contractor Certification Number
Blll's Well Drilling Co. FOR WATER SUPPLY WELL'S 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.)if known 7d.Amount of disinfectant used: 1 lbs
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout Rl 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
❑hxi 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 ❑Groundwater Remediation 300lbs 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 equipment
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Measured depth of well and SWL
4.Date well(s)abandoned: 7-12-23 Disinfected well rn
5a.Well location: filled to top with bentonite
T A Loving Company SEP i go 20203
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
Ir>f�r,�',atctl Pr,:-= Pg tlrA
7209 Stoney Point Rd, Fayetteville, NC1)� DviQhT-_42-23
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 with 1 SA 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:
34.9836843 79.0214339 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
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
abandonment to the following:
6a.Well ID#:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 62 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
i
106.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:
6d.Water level below ground surface: 1 1 (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Sunnly&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also sribrnit 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): (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