Cumberland_Well Abandonment_20240731 (9)

WELL ABANDONMENT RECORD For lnknal Use UNly
This forn :an be uskd for single or multiple%sells
1.Will Cantrectnr Information: W'FLL AB.AVDONMFNI DFTAll
Tyler Brown 7a.Number of wells bring abanduned: l
Well Coutranm hang lot well owtat Nmlretlh alufd.uung%.ca Oil he Ir'1 ptoptrw t i'-1w mldoph olrrrllmr .w rww-wafer ,.kprA� wells ONLY wiA Me soar
./.rr+hrct rr,Ml rd•Il,klNlNlr/II ,•rI .Irl olJl,rrlll,Vlr 1,rrlw
4625A
NC Well CnntraaorCcHlficalw+u Nrn#trr
7b.Approximate%oluaw of waltz rvinuming in trdl(sr (gaL)
SAEDACCO FOR WATER SUPPI.V WFLISONLY:
Cmrtpan+Namc 7r.'fypc of disinfectant trial:
2.Wdl C"Ittrueden Pernk N:,
list Jdl JµryharAle well perwuAr a e,r uwM..v4ae.I ariame.hrfecirclw,etc'.,tl Amlwrr
7d.Aracwnt of divinftYtanl used:
J.Well use(check well aw):
Water Supply Well: 7e.Sealing materials uvcd tc•heelc all that apply'):
❑AFn:ultural ❑MunicipalrPublec ® Neat Ccmcnt Grant fl Bcrrtonitc Chips or PCnCIs
O(icothcrmil(HcannGYbohng Supph I ❑Residennal Watcr Supph iv.ngk) O Sand Cement Grout ❑ Dn(UN
❑Industnal:Comntcrcjai 011mcknual Waicr Supply isharod) O Cotrcrcte Grout O Drill(•nttings
I71fn •tton 17 Specialty Grout ❑Gra%el
Non-Walter Supph Well- ❑Bertlonite Slum I J Other(explain under 7g)
29Nlouuonnc ❑Reco%en
Injectinn W ell: X For each mater•iAl wlemd above.provide amount of materials ased:
❑AqutterRcchargc ❑GroundwalerRensedralicnr Neat Cem.:941b ,Wtr:8gal. Sand Cem.:lb ,Wtr:gal.
❑Aquila Storage and Recmen ❑Sahntn Hamer
❑Agmfer Test ❑Storms aler Drainage -
❑Expentnenlal l achnokg% ❑Subsnien ce Control
?>;.Prn%ith•a brief dcu�riptinn of the abanrhmnncnt prontilurr:
I_ICxothenrial(Closed Loopi UTracer
Bentonite chips to fill the screen and poured grout down the
t iGtrothemra lllieaun Carlin Return) UOtlucr( ainutdt�r' 1 — -----
well
1.Dare%%edit,t ahandon ed: 6-19-24 ta.Will locafion: JUL 3 i 202
Chemours
F;rxilq,On n•1`,.i i. 1'xilpy fDM(if appli"61c)
22828 NC HWY 87 Fayetteville, NC ,/ �rZ�r~' 6/24/2024
Pln sk:;d Addr".(ln.aid Zip St antic of Cenlfied Wen(rnrrrcrafr of w'cn fharcr Dow
Cumberland lilt vigning this form, I hereby cernA-that the well(s) was fwerer ahevttknied In
('outs% I w,d kl:wnl:calkw IN., ;I11\1 ac'c onlaist-e with 114 MCAC 02C'.0100 or:(' 0J00 Re11 Construcltan.Vltncl7rr/%
and that a cryry of this record ikvr berm prrn•hded to the well owner
Sh.Lairilvdc and hingitudc in dtgry v rninutcv%cctmrd%or decimal 44grerv:
01'* It field,one Livintig h,rllletettf) 9.Site diagram or additional well dt•taik:
You new tic live bacl,of this pate:Io pioN tde additional Nell Site details or%tell
N _ W abatdonnteta details Seal rota% also aus_h addmtutral pages if rrecessan
CONSTRIVI ION DETAILS OF Ell.ltil BEING:ABANDONED St BMITTAI.INSTRUCTIONS
.Iff1Ah well Lnn.Urw.lr+.rr round" J;JI WiIAr,Io. ,.r rrcn&yeti ryrc h.,v,!r rr•n .,7q,
%vikONLY with ilk.MNwr[INLtON(rNAf JPW7rAI,rnurnr.fuw can w7,nrlr rule h r tr 10a. For All W'clls: Submit this Corm within 30 dais of completion of well
6a.Will IUat:
PZ-39 ibatdonnicni In the following
Milhi to of W'atcr Restmrre%.Information Procvssing Unit.
drpUt: 10 Ih.l 1617 Mail Senice('enter.Italcigh.NC 2 76941-1 6 1 7
nb,'Ibtal%%ell
10b.Far loieeNun Wills: Ill acdiliou to sending live fora to ilk:address rot lua
abo%c. also sulinut one copy of this form within zn da}s of completion of%Nell
oc.Bltrrltldc diameter;l (in.) abandonnrestt to the tollouirw
Di%Won of Water Resources,Under "Kit nd Injection Contnhl Program.
od.W stir lewd behlw �Ii1tlDd N1rtaPC: 4 (ft.) 1636 Mail Senice Crater,Raleigh.NC 27699-1636
5 Ifk,For Water Sum:Iv& 1 krtim Wells: In addition to sending fire form I,,
(ft•) the address(esl above. Aso submit one copy of this font within %m da%s of
completion of well abandonnrnn to the courn% health departntcta of the:onrA%
6f.Inner Gavin;,+hbinL length(if known): (h.l where ahandoncd
fig,Screen length(if Mown1;5 (ft.)
Font CsW-lit Nonh C'arohm DCwttaRra of Em fronnrcfa:ud Natural Rcsouices-Dts tston of Water Rcsou¢es Re,teed August of t