Cumberland_Well Abandonment_20240429 (2)

WELL ABANDONMENT RECORD FDF Interval Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT"DETAILS
Ken Diediker.' 7a:For Geoprobe/DPT or Closed-Lp Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) ' well cohstruction/depth,only 1 GW-30 is needed. Indicate TOTAL'NUMBER of
n/a (federal employee) weds abandanea:+ I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
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US Army.Corp of:Engineers, Savannah District. 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.)(known
7d.Amount of disinfectant used:
3.'Well use(check well use):
Water Supply Well: 7e.Sealing materials used.(cheek 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
❑Irri ation: . ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry O Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 2 bag
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage"
❑Experiruental Technology ❑Subsidence Control
7g.,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Bentonite chips poured into borehole and hydrated..
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) r_
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- . 02/24/2024
4,Date wells)abandoned. APR G o {; 2r Z4
5a.Well-location:
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US Army- Ft. Liberty t
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Facility/Owner Name Facility ID#(if applicable) 8.Certification:
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Woodruff St. & Glider St., Fort Liberty, 28307 DIEDIKER.KENNETH.D.7507235994/.p9pi,n.N+ j w 04/24/2024
Physical Address,-City,and Zip Signature of Certified Well Contractor or,Well Owner Date
CUmberlalld By signing this form, 1 hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 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,one fat/long is sufficient) 9.Site diagram or additional well details:
35.157774 -78.981559 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 records)ifavailable. Formultipleinjectionornon-w6rersUpplywells
ONLY with the same construction/abandoirmenr,you can submit one form.
10a'. For All Wells: .Submit this form within 30 days of completion of well
6a.'Well*ID#: 69 M W 19 D� abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 32.00 (ft) 1617 Mail Service Center,Raleigh,NC 2769946.17
10b.For Iniection Wells: In addition to sending the.form to the address in 10a
6e.Borehole diameter: 4.25 (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• 6'5 (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 Suimly&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"couinty health department of the county where
6E Inner casing/tubing length(if known): NIA (ft) abandoned.
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6g.Screen length(if known): 10 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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