Cumberland_Well Abandonment_20241014

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lawrence D. Opper 7a.Number of wells being abandoned: 2
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
constructionlabandonment,you can submit one form.
NC 3322-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
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Regional Probing Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: WM0600957
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List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown ]d.Amount of disinfectant used:!,
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout I RI 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
OIrrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation MW-17-Bentonite Chips: 104 Ibs
❑Aquifer Storage and Recovery []Salinity Barrier DMW-1-Cement grout:25 gal
[]Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer MW-17: Filled/hydrated from bottom-up';removed well cover,backfilled and graded surface.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
DMW-1:Tremie-filled,removed well cover,backfilled and graded surface.
4.Date well(s)abandoned: 8/21/2024
5a.Well location:
Crown Cleaners ��1 2024
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
103 North Main Street, Spring Lake Lawrence Opper,� °:- V/2-024
Physical Address,City,and Zip Signature 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.0l00 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: I
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well dretails:
35.166530 N 78.976347 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)if available. For multiple injection or non-water supply
wells ONLY with Cite same consiruciion/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-17, DMW-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
65, 127 (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 dia: 2 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
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6d.Water level below ground surface approX 28 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail.Service Cc I;nter,Raleigh,NC 27699-1636
10c. For Water Supply&Injection 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
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): 10-15 (ft)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013
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WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
r
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lawrence D. O 1
pper 7a.Number of wells being abandoned:
i
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-warier, supply wells ONLY with the some
construction/abandonment,you can submit one form.
3322-A
7b.Approximate volume of water remaining in well(s): 0 (gal.)
NC Well Contractor Certification Number I I
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.)ifknown
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 ❑ 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)
ElMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation bentonite chips: 1.6 Ibs/ft(25lbs)
❑Aquifer Storage and Recovery ❑Salinity Barrier
El 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)
4.Date well(s)abandoned: 8/21/2024
5a.Well location:
Eastern Blvd. Family Fare#220 F n z t
Facility/Owner Name Facility ID#(ifapplicable) 8•Certification: 'l�t` ''' y
201 S. Eastern Blvd, Fayetteville Lawrence Opper'":m 9/7/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Cumberland By signing this form, I hereby certify that the ivell(s)ivas (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.01001or 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:
35.045088 78.865287 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)if available. For multiple injection or non-water supply
wells ONLY with the same consiruction/abandonment,you can submit one form. 10a. For All Wells- Submit this form within 30 days of completion of well
6a.Well ID#:
MW-1 abandonment to the following:
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Division of Water Quality,Information Processing Unit,
6b.Total well depth: 16 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
well I.D.=2.0 above,also submit one copy of this(form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
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9 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Ceriter,Raleigh,NC 27699-1636
loc.For Water Supply&Iniectiori 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): 6 (ft.) Where abandoned.
6g.Screen length(if known): 10 (ft.)
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Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Qualityi Revised March 2013