Cumberland_Well Abandonment_20231101

WELL ABANDONMENT 1
N ONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William J. Miller 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-�o is needed. Indicate TOTAL NUMBER of
2927A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water f emaining in well(s): (gal.)
CATLIN Engineers & Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,Stare,Variance,etc)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
i
Water Supply Well: 7e.Sealing materials used(check Ill that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Gro (,_.. _. l� entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single ❑ Sand Cement GroutDty, lay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout NOV //}}❑Drill Cuttings
Oh-rigation El Specialty Grout NV �' 202%ravel
Non-Water Supply Well:
-❑ Bentonite Slurry - -_-,_,. -3._,,,;•,,,,;11 Otl�ien.(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7E For each material selected a6o`ve,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 50lbs
ElAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete 20lbs
❑Experimental Technology ❑Subsidence Control i
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer j,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Hydrated bentonite used to fill to approximately 6
inches below land surface. Concrete used to bring
a.Date well(s)abandoned: 9/26/2023 opening to grade. All materials left in place.
5a.Well location: j
Mary Barnes Unknown
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
3625 Cumberland Road, Fayetteville, NC 10/16/23
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Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Cumberland 0415-99-2872 it
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
i n provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has be 1
(if well field,one tat/long is sufficient) 9.Site diagram or additional well details:
35.01392 N -78.93589 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 m,ell conslniction records)favailable. For multiple injection or non-watersupply 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#• MW-1 abandonment to the following:
I
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25 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
6c.Borehole diameter: 8.25 (in.) above, also submit one copy of thi I f6im within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 18.58 (ft-) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
tie.Outer casing length(if known): NA (ft.) 10c.For Water Supply&Iniection�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 the county;health department of the county where
6f.Inner casing/tubing length(if known): 15 eft) abandoned.
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6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016

itr
WELL ABANDONMENT RECORD For Internal Use ONLY: i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William J. Miller 7a.For Geoprobe/DPT or Closed-Lo Ip Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 his needed. Indicate TOTAL NUMBER of
2927A wells abandoned: i
I.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers & Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ifknoum
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
[]Agricultural ❑Municipal/Public ❑Neat Cement Grout j IN Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout" ❑Dry Clay
❑industrial/Commercial ❑Residential Water Supply shared ❑Concrete Grout N U7;Drill G ttin s
❑hrigation ❑ Specialty Grout "❑ Gravel,
Non-Water Supply Well: ❑ Bentonite SlurryN�y �J � C ZQQ3 Jo ther(explain under 7g)
IIlMonitoring ❑Recovery
Injection Well: 7f.For each materlial;�elecZed apoVe;,proyide an
)ount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete 201bs
❑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) Hydrated Bentonite used to fill to approximately 6
1.inches below land surface. Concrete used to bring
4.Date well(s)abandoned: 9/26/2023
opening to grade. All materials left in place.
5a.Well location:
Mary Barnes Unknown
Facility/Owner Name Facility ID#(if applicable) It.Certification: �^
i
3625 Cumberland Road, Fayetteville, NC 10/16/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Cumberland 0415-99-2872
By signing this forin, I hereby certify that the ivell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with l SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has beery Provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.01392 N -78.93589 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
ANaclr well conrtrttction record(r)ifavailable. I•or utttlliple iiyeciion or non-u,aler supply trelis
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#: MW 2D abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 65 1617 Mail Service Center,Raleigh,NC 27699-1617
I '
10b.For Infection Wells: In addition ao sending the form to the address in 10a
6c.Borehole diameter: 8.25 (in) above, also submit one copy of this lfoim within 30 days of completion of well
abandonment to the following:
20.63 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Cen'ter,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
NA (ft.) 10c.For Water Supply&Iniection 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 the county health department of the county where
6f.Inner casing/tubing length(if known): 60 (ft.) abandoned. I '
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6g.Screen length(if known): 5 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016