Cumberland_Well Abandonment_20240212

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILIS
William J. Miller 7a.For Geoprobe/DPT or Closed-Li op 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 is needed. Indicate TOTAL NUMBER of
2927A wells abandoned: I
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NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineer and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction perinits(i.e.UiC,County,State,Variance,etc.)rfknown
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
❑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 ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry S Other(explain under 7g)
SMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 87.5lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
Concrete 1601bs
❑Aquifer Test ❑StormwaterDrainage
❑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 —4 inches below
TOC. Concrete used to�fill remaining 4" of casing and
a.Date well(s)abandoned: 12/11/2023 the bottom —1' of the well vault. Gravel from the site
5a.Well location: used to bring the remaining opening to grade.
Public Works Commission of the City of Fayetteville
Facility/Owner Name Facility ID#(if applicable) S.Certification:
2274 Custer Avenue, Fayetteville, North Carolina p' 2/2/2024
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Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Cumberland 0459008872
By signing this form, I hereby certify that the tvell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0I00 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.098932 N -78.829795 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
Aftachwellconstructionrecord(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same consiruction abandonment,you can submit one form.
10a. For All Wells: Submit thisl,form within 30 days of completion of well
6a.Well ID#• RW 9 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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:
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6d.Water level below ground surface: 6.42 (ft.) Division of Water Resources,Underground Injection Control Program,
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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 form to the
address(es)above,also submit one'copy of this form within 30 days of completion
of well abandonment to the c iilt�t�,N.,I1p ih dep men�t,mof the county where _
abandoned. � �
6f.Inner casing/tubing length(if known): 3'9 (ft.) `L "= t L`
6g.Screen length(if known): 11'1 (ft.) i FEB 1 2 2024
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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