Cumberland_Well Abandonment_20240731 (22)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Borror 7a.Number ofwells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) hor multiple aitection or non-waier supply wells ONL Y with the same
4308—A construction/abandonmeni,you can submit one form.
NC Well Contractor Certification Number
71h.Approximate volume of water remaining in well(s): 25 (gal.)
Blll's Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable well construction permits(t.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: 1 lbs
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout [?] Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential 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)
❑Monitoring ❑Recovery
injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 400 Ibs bentonite chips
❑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 Removed equipment
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Measured depth of well and SWL
a.Date well(s)abandoned: 10-5-23 Disinfected well
i_,�✓
5a.Well location: filled to top with bentonite 1 2074
T A Loving Company 3
S Certification: t
Facility/Owner Name Facility ID#(ifapplicable) .
8262 King Rd, Fayetteville, NC 4-, a' -10-5-23
Physical Address,City,and Zip Signa a of Certified Well Contractor or Well Owner Date
Cumberland By signing this form, I hereby certify that the well(s)was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.982379 -79.033988 You may use the back of this page to provide additional well site details or well
N �� abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. bor nmhiple injection or non-waier supply
wells ONLY with the same consiruchoNabandontneni,you can submit one form. 10a, For All Wells• Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 74 (g,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
4 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
35 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (n•) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Sunoly&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
where abandoned.
6f.inner casing/tubing length(if known):
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013