Cumberland_Well Abandonment_20220530

WELL ABANDONNILENT RECORD For ldcnwl Use ONLY:
This fohn cats tie H€cdAr single-or illulOpkwells
1.Well Ciintractorinformition: 1:6 IVELL ABANDONMENT DtTAitsi
Chris Ruffer 7a.Number of luells login%Abanda ed:
W+1fC4r6rac8orNaarc(brt�cl[oirecrp_tsanallyhkia fonts uLilonfiC+tlteipruperay) Feu tiltdijp?e- illje�wmr by iwn-livifer sirppt6- Kilffic, MLY wA Wk ja-A6
ITC Wc11 711.Alipiroxiniate volume ofysater:rcnwinmii g in
j�,q ritio v r(64 4 1 eTQ-1 6 D n N1 I I rb CIT
RECEIVED FOR WATER SUPPLY NULLS 010-Y.
SAEDACCO Inc
companyNamc MAY 3 0 2022 7c.Type qfdi,�nketant riled:
2O4Vell.ConstructEon Pemit#*,
fjkqQlt1B0G1- Id.,Wountof& fedatifuseA.,
3.Well mk,(4;ht;cl;w' el1 wic):
witer S"Pliky Well, 7a Sp'aling materials used(Odck till 6.4 apply);
13 AgricAuTil Mitni c-,llw p tl�i�, DiNot Ccniqdt r3wit'i 13 Hcr-Wrij(dChi6soiNMAs,
110cothcriv:41 Mcating/Cooling.SiTply) 011csidcritLal Watcr Suppb-(single) ❑Sand Pcnti!nt'Gr6ut 11 Dirt*
11hidusirWiConintcrcial' DResidenthil Watcir Supply.(sIxilcil),
El Sp:!CiAlkv,qtoUf b dtayei
Non Water Supply W016 M BentonjwSlum 0 Other(explaiffund6r.7g)
1nqqgti!in Well:' X For each material selected abo,veproside antowt ofmAterials 115c&_
1JA rP=fiar_­6 lGiLddiiition
ilidf� _. , - r I Neat Cem.:3461b Wtr:28gal. Sand Cem.:lb Wtr:gal.
EjAqUdCf S1bt3_4 'cry
ark]ke�ol' 0�ftuni(v Barrier'
C.
Bentonite.:Slb Wtr:gal.
E]AquifeirTest OS16rum-alci-Draillaw
Provide a 1p f d6cription ofilic oNifidninnent proFOure:
IlGeothennal(1P!asc.d Loop) wracer.
Oirnai(HcaEint?)Cooijp Used tremie and pump.
Gcotfic Rctung— under ZS)
4. abalffloncd: 4-14-2022
5a.Well.lo'cation.
Chemours
8.Cer0kifilail"
1248 Bill Hall Rd White Oak, NC 28399 Cumberland C "ChtIS ft 4/14/2022
PltysicatAddrc'ss;City,slid Zip W01 Ovwr_ t3aw
Cumberland 11 th&/ami, I hereby cerfify Ili-at Ille well(s)teas(here)abaHdDijed ill
Nrcil hkitfifi6iitiii it No,(PO I vtrlrrlrce i I tieffe ISA JVC4C 02C,Olkor
tilrdifral a copy oftfris record bars i;>eij provided,lo,'Ilze well owiier,,-
degrees:
9.Site diagram or additional well details:
You luny i9e th N
e back Of dais O,to'Pliovide additional Well site 661s.dr iVell
N
cowrRitcrioz-4 i)rTAtLs-ov WELLdSI]3kiNG AHANtjdNilli SIMHTTAT,jN-5TRUCTIQNS.
,ftAltb rewMov it P!6r irudliplr Mjiecdlin ar mfjoiveff"Pph,
-1hN farm xvitWn 30 days lua. For All'Welb; Submit Hits af.conipletibn of well
66.Well 116901w-9D abanddi-inicitt to the follaiving'-
Divislan of WatcrRcsourw%,Inforwation-Processing Knit,
6b.Totaliv6ll,depth:"49 A) 16117 Miti.1 Sci-%icc
1011.F-Pi-IniMio"Wells: In addlfi&to sebdiag thei,form to t116 address in.16a
aboi,�4-also,subolit one copy of ibis toh'li�8itli[ij i0i'&ys al"C*Wnpletidn"Of"We'll
6c.Borehole diatneter..2 1110 abrido'nnicvtl to Mlle following:
Dhision of%Vawrltesoukesj Un&rgrouiid Itijection Control T-rogratu,
6d.Water lev "in el bclo�v, cl stirfitce- [ft.) 1'
1636 Mail Senice Cotter,Cotter,W-Ici-,l Ni�2169-1636'
10c.For A'slater-2ipply& TnWLon Wells, In addifian-to sending the foml to
6 v,0 u t er casing I eng4h(it L-n ow n): ft) the address(es) above. alga submit one copy of-this farm withk,30 days of
compiction of n-cli abandawncrit to the,courity health Ekparinicut of the county
6j.1"ner"Ca.iinot1l;ing len�jll(if h-no1vu): 4 0 ow wh=ibandowd,
6g.Screett length(if kupiili):4 0-4 5 —00
Pam,dW-10 North C=fim Doparlitierd ofEriv.irourwrit and Natumi Resowres-Division of%Varer kcsoa=s Revised Ajiguu 2013

WELL.ABANDONMIENT RECORD For IdMial Usd ONLY:
This foie foube used fast.single orinulijote wells
1.W01'Contractor information: VVFLL ABANDONMENTI)JETAII-S
Chris Ruffer 7m,Nuniber 61 tvejli being abando,ned:
JudN[WILMY Md Ar , wjflfjpk, I dilmfalf or ,rapt-IiW& siipjy%, t4iLA, MLY 'wegi :,-;k mwe
'"Jibi it ot,e fdrzjl.
MuTtcr 71p.AppriminAtcmlinne ofitattT veil"Ming in Ivel!(s). (gill)
MAY 3 0 2022
SAEDACCO Inc FOR NVATF4,1K SUPPLV 1VFLLS,,0NLV.
1n4wwaU5-n FIF3UM-35".- MM 7c.Type of disinfectant wed-
Zq NVpll.Construetion Permit
?it.Amount of disintec(ani used:
3.Well ust(ebeck well use):
Well .1 ..
Water Supply Well: 7c.Sealing firaferlals:w;cd(cl1ev:khII that apply):
CcMG' ,Rcnt6nft�Chip,orN let
EjAgrkultunil limunic M Nca_ utL(jMjjt: 0
'Qt3cqIhcmLil(Heating 13 Sand C�ntcnt Grant E3 Div Ckkv
)Coofind Supply-) nitesidmW Water Supp4-(sing-le)
13 It4ustriallconuncrei"d EIRcsid6mW WaterSupp4,.(shared)
El Gravel
NonAVater Supply.U!,dE M Bentoni(e Slug U Other(exxplaiirunder 7g)
®Monitoring, Okecovery
"ectinn Well: X For 60 uvAteriA selected above vprodileaniount ofiniterials used:
E3Aquikt,Pecharc-6 Neat Cem.:3461b Wtr:28gal. Sand Cem.:lb Wtr:gal.
ElAqa ikr Stotage and lkicm-ery EjQioh,Barrier
13AijuifL+Test bS toffinvatcr Dviii,i;ge, Bentonite.:Slb Wtr:gal.
-ide'a bel a 7-r Prok eUdescripti,an qCilic alp nikininent 1pqpei9lurc:
06cothennal(Closed Loop) Mincer,
C36corherml(Head!P, Used tremie and pump.
,LCooling Return) 130ther(explain uMer 7g)
4-14-2022
.5&Well.hicatIoKIP.
Chemours
racilkiOwndfNamo rXilily IDA)(10Ppj.=bf0
1248 Bill Hall Rd White Oak, NC 28399 Cumberland C 'Chd8R.uffer' 4/14/2022
PJe'sica]'Addrcss,City,,ditt!Zip 61*1�lor 0q-%V,01 ovwr 13aw
Cumberland By-Vigliyjk-t12iVf0-Vnl1 I hereby cerfify that dw irefl{.s}w"(were)abMidolied ill
counky Panel (PIN). 6- e�qiL �,U VISA WCAC 02-0.01010.or 20.0200 TVVII 4CVjjVj!jjjCfi&lj Staridar,ds
i7qd&M,a copy otiiiis record has bi"xig provided,(o'lhe well awner.,
5kUtitu de unit l6pi0iu6 In ftiviestillou
9.Site ill agram;or,ad ditional well detalls:
YOU- we tbe-back of tfii�page -id6 additional 'It site&Ols,or ivell
qiay ge;to ptin we le r
-W abandonjiiertvddtail,. "Vbd w'Cessm-
(:6NSTklJCTlbX l3kTAILS 09 WELL(S)BEING AH,' NDdNiD 5UBI1TtTTAT,1FNSTRUC.TtQNS,
Ath,)df 11WI waviraelmro KiElrvvxl it i2041alk. r6r ind4de w x4pp6l
10a. Far All Well-• .Submit-Ilik faint-.iitWn 30 day of completion or well
-1Nnd6k1nJqnt to the following
DI.Visfiin of Water cessinallnit.
IdIj Ala ,
6lpADtaIuv1Ideptk.. 49 00 it Si�rvzC e
e 'cut&,Raleigh,XC 276594617
—
tOb.-For 1mlec6onWells- 4iadditii54to.sendinifliefornito the addiesiiiii63
fir.Borehole illattleteT-.2 'abbw�also'suluftit one copy of this fb of 10,01up'letioni of lvell
abikidonat.ent ter the following:
111vision of Water Resouries;UnderAround bijection Conlrbi I�rdgratu.
(oil.Water level belowgqound surface'.' —00 1636 M nri ailSec c utcr,Raleigh,­6 ' NC,274994636'10c.For Water @ipffly-&Infeeg2n WeRA: In addition(o sending the forin to
6c..Outer casing length(if known): (ft) the iiddress(es),4bove. also submit one'copy of this fonn Withior 30 days of
coinpiction of well ibandoninent to the.cbunq-Health Elepidincid'of the county
6f.linier eaq -ib-
inoullin 'jength(if 1,�o' 0). 2-5 wli=. fndomd
4)
Q,,SerCvn,lvnpth(if known):2 5-3 0
Vonn Q%W-36 NanhCaratimMpaniocd ofErwimnnrenk wd NaturatResow-ces-D1yis[bno Water RCh01LMCS Revised AtiSLM 20 t3,

WELL ABANDONTNEENT RECORD For fildmil Uw ONLY:
1.Well Contractor Information. DONNIENT DNAIU;
Chris Ruffer 7a.Number of uells being altallitioned:
I,te(Or we,I aliaiitt oA'Qkbfi iiisell,er PIOPMY) +``+r lindriple fAred(mr, a; 'Imd-liv'ifew airitsi AOLs &NILY w1d) flk salon
SAEDACCO Inc E C REGEN FOR WAUR SUPPLY BULLS ONLY.
COBVany Name MAY 3 0 2022 7e,Tyre ordisinfectant Used:
2. Construction Permit#.
L�1,41 IjA-MV,4r11 pel-11h,'O�e- Wy,S171e,J'u dwi MW M 1Y4JR,*M_6e-.:4r g U n Id.Amount of disinfeviant used,
[AMBOG
3.Well use(check ii ell use).-.
WAter'S pply'VVell: 7c Scaling filaicriiats,used(0661;all that apply):
Od NCcnicnt'
INat .Qrultt
Ekk9thcraut(Hcatinjer'Cooling.Supply) EllicsidcntLit.%V.itcr Supply'(,- _le) b Sand,'Ccijtclll Grout 0 Diy Clti"
11 hillustrW/Commercial EIRcMdential Witter Supply(sbaroti) 13 C6n&.re(aGwu:t 0
❑Itri tiara n 5PO.LiakLy Gold 11 6ravel
Non-Water Supply W.011; 69 Eintonite Slurry O'Oflhcr,(cxT1ain:under 79)
11 Rtcovery
Injection Well: X For each material selected above,pro kide amount of.,mMerials used:
U,Aqttiter Rcciia Reutedhition!ge Neat Cem.:3461b Wtr:28gal. Sand Cem.:lb Wtr:gal.
o4quifer Storage zuki Rectwery ENAiuifv Barrier
I❑
I lAijuif&Test bst6illAVaLcrD-ra-huiEw Bentonite.:51b Wtr:gal.
OE+arerintental Tuchoology p8libsideocti Cbjaltul
7*Pxovidi a Urk!"desicriptilin of the altandnoment nrvlc dun:
1:16cothearmal(C!oscd toop) OTneer.
®Geothenualtl3cttinCooli2a Return) ®Other(es 2lain under?g) Used tremie and pump.
4-14-2022
&L Well.locat.ion.,
Chemours
sicertificalich.
Fxfliw rim orappikabio
'Chri's RUffer'
1248 Bill Hall Rd White Oak, NC 28399 Cumberland C 4/14/2022
Physical'AAftss,Cily,.afid Zip siinillroorce;tifil wractor or Well Ovtr:r Dole
Cumberland 1r,&mby certify duir Jfw wefip;)urns(were)a.hwidoned.li,i
bit* Raf&I ldentitF Upti No.(PIN). acconkfilce Itiffl?154 Jvcilc 02d.01 G O.Or 2C.0200 Wel[Constnictioit Standards
iwdlhrrt a copy afelds record kwt hqvi provided/olhe'tvell owner,
9..Site i diagram or additiortal well details:
you 1"Oue tile bcklof this pa I_e a I
!to provide additional well site details.or Wcll
_N W abandonoteuttletaiL You
CONSTRUCT1(7NjiftAIL5,OF%VrLUk)BEiNe.AkkkI16Nkl) SIMMITTAL IN-STRIM.TIQ S.
10a.For All %V&s: Submit thki thrut4itWip 30 daysv of completion of well
6a.WV11 M :.OW-6 aWndonnicht.to the following.
g
D!VisitinufWntctRemurcL%,Inforinatitin-Patel-A.SiBL!Unit,
6b.,Total ivelldepth: 60 1617 Mail Service Center,Rileioi,KC_27094 617
10b.For fit lecGo"NN Vis: Iii addition t6sending-dke'fomkto the address-In IN
41boix- aLso,Athmit one coley of this fdrm,vvithi�'30'days of coiuiilei"�iif'iveil
fie.Borehole diameter.2 abatitionnicul to tile rbljowing�
Dhislon of AVater Resourees;Undergr6und hijpa!on Contibi Program,6d.Water level below.ground stirfacm. _00 1636 liplail i6vice Ciente'r,italcigh,NC 276994636
10c.Fnr I'Vater-Stionly,fi-hilectflin Wells: In addition to ScRdingthe forni to
6c..Outer casing length(if known): tile,address(es).ab&6. also submit oil& copy of this form within 36 days of
completion of wClI o'bandourticut to the county lictilth dc�partnlc'nt of tho county
6L Inner cain W11cruabqndioned,
so
. plubirig length(if loplown):
6g,Screen lenki h(if knoit 0:5 0-6 0
Fami GAI-30 Non h Carolina Deportment of Environment aiyd Natural Resowres-Division of Water RLSO ILMVS Revised A4gust 2613

WELL ABANDONMENT RECORD roT Iddikil U,.w.'ONLY:
Thus formcan b6'4cdfi6,r single or nitilliplqvcIls.
1.Well CanthiciOr lo(Ornwitim 'sVPLL ANAND6NNIENT DkTAMS
Chris Ruffer 7a.Number 4,n ells being aliando I Hj,
' "rprapelly) Fay iMiMple. 6tpe mr. Or riwa-war& Litiffic ONLY wA .flm sam
jan..,well on h I,ithe
yqre
E IVE D 711-AliProxin, r Voluiof C 3iater'nird
M in well(s)*
FOR NVATFig,05UPPLY I�IFLL$ONLY.
SAEDACCO Inc .3 0 zozz
Compaiiy Name e4zing UK9 7c.Typ'cii(disinfectant 64cil.
:Z:Well Construction Periffit
L U-dl apphleable tiellperitti&(Let CZ;rzh-_,-SiAr.-m-,Yarfwxe,hbectknl,ejc�j!fk-wL41
-7d.Amoud[Of disinfectatifused:
3.Well use(check i eu use):
Water Supply Well: 7c.Scaling Matcdalkoscd apply-):-
bApTirultuml limuniq-IMIA1111blic- Ud Nc1tCcMcntCjroot El Bcotonite Chips orPcllcts
Mcollicrimal(HcAng/Coolin,,i.SiTply)- DResidential Water Supply(single) ❑Sand Cen.t4it Grout [I'My Ckq
13hidustrial/ConancrCial EIRcsidential Water.Supply(shared) 11'Condew Grout 13"Drill Q41i tigs
13 specialty Grout b Gravel
Nan-Mlater Supply Well: M Bentotifte Shiny 11.0idler(explain under 7g)
®ilaliltorine
Injection'Well: X For each material selected ab6vWiiro%idc aMQI1Dt Of.MatffialS MCII:
MIGr6iifidivatir R ntqdintiqn Neat Cem.:692lb Wtr:56gal. Sand Cem.:lb Wtr:gal.
uptifer Stot ge and- cewery Mader
,6�uifei�test bS torinivater Draimwe Bentonite.:51b Wtr:gal.
b
EiLverinteutal Technolqgv
'7*Provika 1pek-f description Of ijlji�.abandonment p
.. Provide "I p I . . . I _­ ," , I
MCwthernral(Closed Loop) riTracer.,
Used tremie and pump.
4-14-2022
15&Well.location:
Chemours
ra0IityMivm-rNamc nnilhy um(f ippoc-able) S.certifica tiall:
ri8` R 4/14/2022
1248 Bill Hall Rd White Oak, NC 28399 Cumberland C CN Uff&
...........
Phjvsicat'Addrm City;acid Zip Dine
Cumberland I hereby certffij-#zai 1/w ireflfs)was(wer,-),obajjdoj{ed4,n
QUILYLY PaI&I Id2jitif te iIkht No.{PING accvnicifice ik1h 15A XCICNC.0100.orX.6200 lVr,,MCvmY"cU6a Starlikirds
and 1111�'a cop}!of'd-fis record I=bqci i providedta.-fire well 6 imen-
ft.L ntitudeand lmi0,(ndc in tar degrees;
�Ii r ') . . ,
(irisri, 9..sitle diagram or additional well details:
to-pwidd addkional AvOl sit,&641s,or- I
You ga a I wel 5 a*ba&of p�gfl on:
W a6au Ctt'ddaifs. You
t7ONSTR11CTION DETAILS Olt WELL(S)BEING.ABANDONED SIMNUTTAT,tNSTRVLTFON­S,
10a. Nor--All Welk Sulirdit IhLli forinxiiihin 30 days of c6nililctibn of wall
abandonritc6t to the followin'g:
]DI'Viii6n,Of Water Resources,
6bAotalisvid depth, 65
10b.Por Inicelion Mlylls: In addition to.setidingt1kform to the addresilu Ka
Borehole diatneter:j 6c. %
(in) �bow also stflijuit one copy of 68 faint withiii 30'diyq of completion.af'ivell
, _ .
aba'adounte'iti ILI IL following:
6d Water level liclawground surface (ft.) DiAslort of Waterl1csourkes,Underground Injection Control Program,.
1636 Mail$cnicc(:cuici,Raleigh,NC 27699-1636
6r-.()utcr ca.sin lengo,(if lwown): ift) In addition to sending Ilia form to
g
.the address(es) above. ago kilimit.one copy of ti1js' faint within 30 days of
c.roptetibn-of well abandown.-tit go the county health deparmicni of the county
6L Inner casinorobin..length(if tanown): -9 ,kVhaTC 0 abandoned,
6gg.Strecti length(if loom n):40-65 —(ft.)
Form GNAI-30 Nonh'Camlln3 Depannicoi of Enyimmitent and Natupt RCSOUMCS—biViSiCul Of WhICr RNMECS Revised Augud 2013