Cumberland_Well Abandonment_20240710

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lawrence D. Opper 7a.Number of wells being abandoned: 5
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the some
3322—A construction abandonment,you can submit one form.
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): 0 (gal.)
Regional Probing Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ijknown 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 0 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 ❑Other(explain under 7g)
OMonitoring ❑Recovery
injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation bentonite chips:1.6 Ibs/ft(20-24 Ibs/well)
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g-Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Filled/hydrated from bottom-up. Capped with concrete.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
MW-1(15'),MW-2(15),MW-3(13),MW-4(15),MW-5(15')
4.Date well(s)abandoned: 5/23/2024
.i Sa.Well location: -)� ��`r�• v
Jones Small Engine Repair NCDEQ Incident#29626
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: JUL 1 0 2024
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4800 Bragg Blvd., Fayetteville Lawrence pper4^-_mm,,.,, Ft�+a►> � ?+�-,�t u
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner `.dies
Cumberland By signing this form, I 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 lat/long is sufficient) 9.Site diagram or additional well details:
35.09139547 78.9539701 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)ifavailable. Par multiple injection or non-water.supply
wells ONLY with the same construction abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: Monitoring Wells-see 7g abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
13-15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
well ID =20 above,also submit one copy of this form within 30 days of completion of well
. . .
6c.Borehole diameter: (in.) abandonment to the following:
7-j Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
1Oc. For Water Suuuly& infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
6E Inner casing/tubing length(if known): where abandoned.
(ft.)
6g.Screen length(if known): 10 (ft.)
Form G W-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013