Cumberland_Well Abandonment_20230915 (31)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Sebastian Britt 79.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-ivatei supply wells ONLY with the same
constructionlabandonmenrbmit one form.
4567-C 1,you can su
NC Well Contractor Certification Number
7b.Approximate volume ofwater,remaining in well(s): 21 (gal.)
Billrs Well Drilling Co. FOR WATER SUPPLY WELLSIONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit#: il
List all applicable well construction permits(i.e.County,State,Variance,etc.)lfknown 7d.Amount of disinfectant used• 1 l bs
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout O Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
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❑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 ❑Storrtwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description ofthe abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Removed equipment ( :
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Measured depth of well and SWL
4.Date wel(s)abandoned: 4-18-23 Disinfected Well
59.Well location: filled to top with bentonite
T A Loving Company JrP i �n -
on
Facility/Owner Name Facility ID#(if applicable) 8.Certiicatt
�/�� ma 15643 Toggle Ave, Fayetteville, NC X,��' y� �r"�OPRP23 u�
Physical Address,City,and Zip Signaime of Certified Well Contractor or Well Owner Date
Cumberland By signing this form,I hereby certify that the well(s)was(tvere)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C 10100 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:
34.9869812 -79.0252570 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 ivell construction record(s)if available. For multiple injection or non-wafer 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. 50 (lt-) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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:
18 Division of Water Quality,Underground Injection Control Program,
lid.Water level below ground surface: (B-) 1636 Mail Service Center,Raleigh,NC 27699-1636
loc.For Water Sunaly&Ini ice
Wells: In addition to sending the form to
6e.Outer casing length(if known): (fL) the address(es) above, also submit one copy of this fora 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):
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of WaterlQuality Revised March 2013