Cumberland_Well Abandonment_20240731 (29)

WELL ABANDONMENT RECORD For l,aerrtal I x ONI V
This form can be used for single or multiple»ells
1.Well Contractnr Information: W'FLL ABAVbONMENT DETAIL K
Tyler Brown 7a.Number of%efl%being abandoned: 1
WellCowaaw Naar im%ellownrNnonathaltaeklrtregwemonhi%Aterpropen)I f,w mrlolrh Poor,eum ,w ,s.,r- we, .igyV) rents O,VLi rorb the .,.ate
..wrrgt;,vi ahw"vi "sr.IriN I'MI,uhnur,Nh'i(rrm
4625A
7b.Apptttsimate volume of water•remaining in iAdIOP/A I gal.1
NC Well Coninctnt Cerliftcaiion Nainkvi
SARDACCO FOR WATER SUPPLY WFLI S ONI.V:
Coupon±Navw 7c.Ti Ile of disinfectant used:
2.Well Construction Pe•rdt
hxr rdl gvikable w i'l lwm7x ax-(conn..1,mr.I anw¢e hveiiNim ere i i/l)ffrrN
7d.Amtmmt of disinfMant used:
3.Well use(%heel%nell use):
Water Suppll Well: 7e.Sealing material%u%cd(cheek all that apple):
❑Agmcultural ❑municipalrPublic R Ncat Cement Grnlit ❑ Berdonac Chips or Pellets
❑(iemlterntal(Hcanikg-Vooling Supply) ❑Residcrttal Water Supph Isinglc) ❑Sand C'emertl Grout ❑Din 03'.
❑Infustrialr('omntciriai ❑Residential Water Supph (shared) ❑Concrete Grout ❑ Drill Cullinp
❑Irri •ttun ❑Speoalh Grout ❑Gra%el
Non-Water Supply Well- ❑Benaoude Slum ❑Older leeplain under 7g)
QOMo(a(onue ❑Rccu%rn
Injection Well: 7f.For each material%circled abo%r,proAde sawwat of materials owd:
❑Aqutter Recharge ❑ munduater Reniedution Neat Cem.:941b ,Wtr:8gal. Sand Cem-:lb ,Wtr:gal.
❑Aquifer Storage and krcrn rn ❑Salmi)% Wooer
❑Aquifer Tess ❑Stommater Drainage —.
❑Ecpetmental Technolop ❑Subsidetux Control 78•PrwvW a brief description of the abandonment procedure:
U43gothemtal(Closed Loop( LITracer
i lGeothemral(Neatin 'Coolie Return) I.IOdwr(ex aim under 7 ) Pulled well out and poured. grout into hole
4.Date videos)abandoned: 6-14-24 6,•.,:::;.�' �! i
ta."CH location: �I - 4? M-2
Chemours d+ �"f
FaciIkyX]h%wr Naar Facility IDM(if appikiblrl 8.CerlfllCarM: �
r �?22828 NC HWY 87 Fayetteville, NC ��s},,,j���,,,/// e`.� 6/18/2024
Ph+5K8I address.C In.11d Zip '�� tarot WenOww:r Dale
Cumberland !ri sipoo g mac farm, i hemoy cernA thm the welf(sl was(uerei ahtmidoned sir
Cautrtl Fmd ld.ni:l:c.uwa t� i'l� ur<'onlanre wid1 1JA.VC.4(-0.`C.0100 or X ai2W RIel/Ccnstruc•hon.Vim(Aisrdx
and that a cripy of(hie record has been pre vuW to due well owner.
Sb,Latitude and longitude in deytrees mimdtr%:%ceond%or dcc•imal dty urns:
0twell fr<id,Otte Wu long t,wilte:rcm( 9.Site diagram or additional well details:
You rtt:t% the the back of this poge to pun ode additional Nell Site details of Nell
abatdoontenl dcuib Yost ow also attach additional pages if neceman.
CONS I R1'(TION DETAILS OF«ELIAS)BERG ABANDONED SUBMITTAL INSTRUCTIONS
.iiLx/r null rrrrslry�ln nt rrn•nFv:!nwhe'4. ..w nmi(tj.lr uyec luau err rrm na,rr rn(g•ir
wellsONLI'anhrw.)iwt4n.oral(Nor.NwrJoomral-i,w wr+ahmocureh.nrr 10a. For All «Cob: Submit thts farm nithm ;0 days of completion of well
6a.Well MO:INSTTO-02 ahatdonntcni to the following
Di%iskin of Water Rcwrnrceti,Information Procession;I nit.
1617 Mail Senior Center,RalciKh,NC 2769)-1617
lot),Total null dcpdi: 17 Ih.1
10b. For Iniection Wells: In addition to seodmg the form to the address sit Via
abo\e. atw sulmin out:cup.N of this form within 30 days of curnpiction of urll
6c.Bomhole diameter;1 tin.) abatdonotem lu the rollo%rlilt,
Di%Won of Water Resources,Under=raimd Injection Control Program.
bet.Water k•%rl hrillw 2tround wriarrc N/A (ft.l 1636 Mail Smier Center,Ra ei2h,N('2 7699-1 636
6c.Outer casing Icngtk lit Loon n : (ftl lOe.For Water Summh & Iniecrkon Wells: in addition to sending the form to
the address(es) above. also submul ooe cop% of this form %%illnn lm days of
completion of urll Amidomncnt to the colon} health department of the count%
u lief%abandoned
6f.Inner c asingltobing tun gt h t i f know Ili: (ft.)
6g.Screen length(if knonn1;10 (R.)
Font GW-ill Noah Cmohm Depranmeri of Em tronnkm;old Narmal Resowces-Dhmoos of Waur Resourc>-s Re.teed Aupsi 14)IA