Cumberland_Well Abandonment_20230915 (36)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on histher property) For multiple injection or noimrakr supply wells ONLY with the same
constructioWabandonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): 24 (gal.)
Bill'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.)if known 1 lbs
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaltPublic ❑Neat Cement Grout O 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' i.
Injection Well: 7f•For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 300 Ibs bentonite chips
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stornwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer removed pump equipment
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Measured depth of well and SWL
a.Date well(s)abandoned: 3-22-23 w j.V F _ Disinfected well
5a.Well location: c C P 20�� filled to top with bentonite
T A Loving Company J C
Facility/Owner Name CflplUifdb1 � RA 0� $•Certification:
7700 King Rd, Fayetteville, N�., 6�QIBOG 3-22-23
Physical Address,City,and Zip Signa 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 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has bien,provided to the well owner.
5b.Latitude and longitude in degrees/minutesAeconds or decimal degrees:
dwell field,one[attlon is sufficient
(� g� ) 9.Site diagram or additional well;details:
34.986327 -79.018881 You may use the back of this pagei to provide additional well site details or well
W abandonment details. You may also1 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 saute constructioWabandonment,you can submit one form. 10a. For All Wells- Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality;Information Processing Unit,
6b.Total well depth: 56 Up 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:
4 above,also submit one copy of thiI form within 30 days of completion of well
(in.) abandonment to the following:
6d.Water level below ground surface: 22 Up Division of Water Quality,UndeIrground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Sunoly&Iniection Wells: In addition to sending the fort to
6e.Outer casing length(if known): (B•) 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): 00
where abandoned.
6g.Screen length(if known): (fL).
Form OW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013