Cumberland_Well Abandonment_20230915 (38)

WELL ABANDONMENT RECORD For Internal Use ONLY: I 1
This form can be used for single or multiple wells Il
1.Well Contractor Information: WELL ABANDONMENT DETAILS
7a.Number of wells being aband 1 ned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-i"voter supply wells ONLY with the same
construction/abandonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of wate r remaining in well(s): 24 (gal.)
Blllrs 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.)iftnown 7d.Amount Of disinfectant used-: 1 lbs
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(checkjalt 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
❑IndustriaUCommercial ❑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: 711 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 ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description ofthe abandonment procedure:
[]Geothermal(Closed Loop) ❑Tracer removed pump equipment
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Measured depth of well.and SWL
3-22-23 `•`z I -rti3 Disinfected 4.Date well(s)abandoned: Y" �; �t well
52.Well location: SEP 1 5 2023 filled to top with bentonite
T A Loving Company
Facility/Owner Name Iti� ' � 8•Certification:
7654 King Rd, Fayetteville, NC DAlal'BOG 3-22-23
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 ISA NCAC 02C.DI00 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: 1,
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.982318 -79.018831 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may al§I o attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS!
Attach well construction records)Ifavailable. For multiple injection or non-water supply j
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 ID# abandonment to the following: I
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 57 ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
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10b.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:
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21 Division of Water Quality,Underground Injection Control Program,
lid.Water level below ground surface: (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
lie.Oster casing length(if known): (ft.) 10c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit'one copy of this form within 30 days of
completion of well abandonment
,to lthe county health department of the county
where abandoned.
6f.Inner casing/tubing length(if known): (ft.) 4
6g.Screen length(if known): (fL)
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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: i
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
7a.Number of wells being aband I mid: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply ivells ONLY with the same
construction/abandonment,you can subn lit'one form.
NC Well Contractor Certification Number 7b.Approximate volume of water i remaining in well(s): 50 (gal.)
Blll's Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable tivell construction permits(i.e.County,State,Variance,etc.)ifknmvn 7d.Amount of disinfectant used:' 1 lbs
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agriculttual ❑Municipal/Public ❑Neat Cement Grout El 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
❑M 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 500 lbs !' 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) removed pump equipment
X.. ` -- .-� Measured depth of well,and SWL
4.Date well(s)abandoned: 3-22-23 FX�('—,�--,-. Disinfected well i
5a.Well location: SEP 1 55 2023 filled to top with bentonite
T A Loving Company _ n arnCf -,q Ur
Facility/Owner Name � acilirrrr�g , 8.Certification:
ty--y�+�Ql'S�� ;
7654 King Rd, Fayetteville, NC 3-22-23
Physical Address,City,and Zip Signaturt of Certified Well Contractor or Well Owner Date
Cumberland By signing this form,1 hereby cert fy that the ivell(s)ivas(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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.982313 N -79.018802 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 ivith the same constructionlabandonment,you can submit one form. 109. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well II)#• !'
Division of Water Quality,Information Processing Unit,
6b.Total well depth. 97 (g) 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 (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 (fL) Division of Water Quality,Underground Injection Control Program,
1636 Mail ServiceCenter,Raleigh,NC 27699-1636
10c.For Water Suooly&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): YL) 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): (ft.) where abandoned.
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6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water,Qaality Revised March 2013