Cumberland_Well Abandonment_20231101 (2)

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WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILLS
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 I GW-301is needed. Indicate TOTAL NUMBER of
2927A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water i 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.U/C,County,Slate,Variance,etc.)ij'known I
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 a Bentonite Chips or Pellets
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❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout I ❑Dry Clay
❑industrial/Commercial ❑Residential Water Su 1 shared ❑ Concrete Grout "
PP Y( ) :�,{�; -x I3'Dri1l;Cuttings
❑Irrigation ❑ Specialty Grout b-Gravel
Non-Water Supply Well: ❑Bentonite Slurry tJ j 2021
Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each math al selected.above,_proyjdde,atrnount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Gl' `W c� �50'Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage SOII 50 IbS
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Hydrated Bentonite used,to fill to approximately 6
inches below land surface.Soil used to bring
a.Date well(s)abandoned. 9/26/2023 opening to grade. All materials except PVC removed.
5a.Well location:
Mary Barnes Unknown -
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
3625 Cumberland Road, Fayetteville, NC j 10/16/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Cumberland 0415-99-2872
By signing this fornz, 1 hereby certify drat the ivell(s) ivas(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100'or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �and that a copy of this record has been I provided to the well owner.
(if well field,one lat/long is sufficient)
9.Site diagram or additional well d tails:
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
Altach a,ell consirnciion records)ifavailable.For multiple injection or non-watersupply wells
ONLY wifh the same cozslracliai,'abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW 3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
25 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (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: 18.05 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known):
NA 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
(ft.)
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): 10 (ft.) abandoned.
6g.Screen length(if known): 15
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016

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WELL ABANDONMENT RECORD For Internal Use ONLY:
I �
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William J. Miller
7a.For Geoprobe/DPT or Closed- oop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-k is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers & Scientists FOR WATER SUPPLY WELLS ONLY:
r
Company Name
7c.Type of disinfectant used:
e i
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):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout S 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 ❑ Drill Cuttings
❑Irrigation ❑Specialty Grout - 4w;+; a "{]rOravel
Non-Water Supply Well: El Slurry NOV O't)ie i(&plain under 7g)
RMonitoring ❑Recovery tY Ie ��nn
Injection Well: 7E For each materiaal selected above,provi mount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite I�ov� l '- '�'"'':`:*b� Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier "
❑Aquifer Test ❑StormwaterDrainage Concrete 20lbs
❑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
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
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Facility/Owner Name Facility ID#(if applicable) 8.Certification:
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 fain, I hereby certify,that the wells) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC'02C.0100 oi•2C.0200 Well Construction Standards
and that a copy of this record has been pibvided to the ivell owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(ifwcll field,one lat/long is sufficient) 9.Site diagram or additional well de ails:
35.01392 N -78.93589 W You may use the back of this page totprovide 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)ifavailable.For multiple injectiaiornon-water supply wells
ONLY with die same consiriiction'ahandoniiieiit,you can submir oneforin.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W 4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (in) above, also submit one copy of this forth within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 16.68 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,;Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the fort 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): 10 (ft.) abandoned.
6g.Screen length(if known): 15
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

cUMBERt"P`Np
M MW-2D
W-1
FORMER
USTS`
r .
FORMER
DISPENSER
ISL'�AN
,r
MW-3 .
A8D LAWN
r
• MOWER REPAIR -
t
SW-50
LEGEND - BARNES MOBILE P
�� HOME PARK
® Abandoned Monitoring
Well (Type II) +
OAbandoned Monitoring ,
Well (Type III) 44yJ;
© Inactive Potable
Water Supply Well +
❑
Approximate Location pp �.
of Former UST System
❑ Parcel Boundary .
Source:Esr Maxar Earthstar Geog#raphic'`s:and the GIS Use tn
NOTE:Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 50 25 0 50 100
Feet
PROJECT TI T_E
FORMER KWIK SHOP FIGURE
ATLIN 3625 CUMBERLAND RD SITE MAP
FAYETTEVILLE, NC 1
Engineers and Scientists
INCIDENT NO JOB NO SATE SCA.E DRAWN BY CHECKED BY
3601 220275 NOV 2023 AS SHOWN KMC/SJO