Cumberland_Well Abandonment_20240403

WELL ABANDONMENT RECORD For internal Use ONLY:
1.Well Contractor Informati I
on• WELL ABANDONMENT DETAILS
David E.Meyer
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-30 is needed. indicate TOTAL NUMBER of
2527-A wells abandoned: i
i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):0 (gal.)
Protocol Sampling Service,Inc. FOR WATER SUPPLY WELLS ONLY: '
Company Name HTH
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,Calmly,State.Variance,etc.)if known 4 oZ.
7d.Amount of disinfectant used: I
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout X Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
• ❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
❑Irrigation _ 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 71.For each material selected above,provide amount of materials used:
❑Aquifer Recharge 0 Groundwater Rcmediation 200#bentonite chips
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology 0 Subsidence Control
OGeothennal(Closed Loop) OTracer W ovmp andpppipu�n ffr oem awe nwma ilt socndre:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
found free from obstructions,,filled with bentonite chips
March 11,2024
4.Date well(s)abandoned: top 3'casing removed,backfilled and compacted
5a.Well location:
McKee Homes LLC na
Facility/Owner Name Facility lD#(if applicable) 8.1Certifrcation:
4742 Tumbleweed Drive Hope Mills,NC 28371 I - 3/12/2024
i
Physical Address,City,and Zip Signature of Certifies Well Contractor or Well Owner Date
Cumberland 0403469721
By signing this form, I hereby certifr that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0190 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:
(if well field,34.9506$one lat/long is sufficient) 9.Site diagram or additional well details: .
-78.98405 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)iifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
1... 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 1 [.7. ^ `-14 t •.w: " abandonment to the following:
45 rDivision of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) APR 0 e`, 2024 1617 Mail Service Center,Raleigh,NC 27699-1617
4 1Th`i.;;;,",-1 -1 Pr^/;;er31t+t (JF1 1ob.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) DWO 30(3 above,also submit one copy of this fonn within 30 days of completion of well
abandonment to the following: i
ground
surface: (ft.)20
6d.Water level belowDivision of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
na IOc.For Water Supply&iniectionlWells: In addition to sendingthe form to the
6e.Outer casing length(if known): (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):na (ft.) abandoned.
na
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources; Revised 2-22-2016