Cumberland_Well Abandonment_20240419 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETA''ItS
Scott M. Werley 7a.For Geoprobe/DPT or Closed i-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-30 is needed. Indicate TOTAL NUMBER of
3344-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1 -77 (gal.)
ECS Southeast, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
WM0601212 7c.Type of disinfectant used:
List all applicable cell construction permits(i.e. UIC,County.State, 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 ❑MunicipaUPublic S Neat Cement Grout C Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout i ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout I ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout I ❑ Gravel
Non-Water Supply Well: ❑ Bcntonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Neat Cement —30 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier gentonite ^• 56 Ibs
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer I
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) gentonite - gravity'feed from 5 to 40 ft bgs
Neat Cement - pour from 5 ft bgs to surface
4.Date well(s)abandoned: 3/1 9/2024 j
5a.Well location: r"
Proposed WaWa N/At� ' ,' y'
Facility/OwnerNamc Facility ID#(ifapplicablc) 8.Certifi lion: 1 APR 9 2024
3611 Raeford Road, Fayetteville, NC 28304 �, pr,-,ceorok t, I'll 4/4/2024
Physical Address,City,and Zip Signature o Certified We Co actor'or WI11t1,'u�WCs IDG Date
Cumberland 0417-70-7669 By signing this.1brin, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02Ci.0100 or 2C.0200 IVell Construction Standards
and that a copy of this recce d has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 9.Site diagram or additional well details:
35.043321 N 78.941007 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.Formultiple injection ornon-watersupply wells
ONLY with the wine consn•tiction/abandonneent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (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: 6 (in,) above, also submit one copy of jths form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 29.1 5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (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 complq
of well abandonment to the county health department of the coun"here
6f.Inner casing/tubing length(if known): 20 (ft,) abandoned.
6g.Screen length(if known): 20 A)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016