Cumberland_Well Abandonment_20240731 (16)

WELL ABANDONMENT RECORD rotlrtnerttalUscONIY
This form can be used for single or multiple%ells
1.Will(betraelor Inrfnrmatior: WELL ABANDONMENT DETAII ti
Tyler Brown 7a.Number of%ells being abandoned: 1
Well Conmicim Nance tar Nell owirr perwiully ahandnning well on liz.1her property r P. mutat,h uttrahwr ,a ww-,ia&v xirlrply *ells ONLY verb Nk- uvn,
,..ri+nn.nwr„hu,..dw,m•nr „.. .n ,»h�„�r w.. r;..,•
4625A
NC Well CnMrxrnrf cnificalinn Nnn#icr
'b.Appttittinutciniti[n,, -trlalrr,cutalnm'eti.cll(r): (gal.)
SAEDACCO FOR M4TFR1,1 I'll I ) %%fII I1:
Conq,am Lime lylh•of duinfcetant u.cd: _
2.Wdl Coastrvctiun PcnWt M:, ,
Gv rd!yvplauhlr well linens n.e.Como.S ae,I ariLMe hveou,".err.-i/A a-,
-d, lmount of divinfcvtant used;
J.%'ell use(check%ell uael:
Water Suppl}Well: 7e-Sealing material.used(check all that apph►:
❑Agnoiltural ❑Municipal+Pibltc M Neat Ccmcni Grout fl Renilonitc Chrlr or Pellets
❑(iconherm:d 1Hcaagtp'Cooling Supph I 011miderttal Watcr Supph IsuiFlcl ❑ Said Cement Grout ❑ Dn Chu%
❑indusinall'ommcrcial ❑Rcsidcrtial Water Supph nsluircd! ❑ (onncrefe Grout ❑ Drill Cutnngs
01tritgaijoll ❑ Specialtr Grout ❑Graced
Nan-Water Supph%N ell: U Bervionite Slum U Orber leeplain under 7g)
I9hlunntanoe ❑Recrntn
Injection Well: 7f,For each material wlecled ahow.proiide amount of material.uved;
❑AgmkrRecharge ❑GrouridualerRetnediation Neat Cem. :941b ,Wtr:8gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Slorage and RecrA en ❑Salinih Damcr
❑Aquifer Test ❑Stonmu atcr Drauage —
❑Eynenmettt it Technology ❑Subsidence Contrul
7>;.Pntiids-a brief dexriptian of the tihant{inuriret pniatJun:
❑Geothermal 1Cbsed Loopl ❑Tracer
Bentonite chips used to fill the screen and poured grout
DGeothemtal Meatio ,'Coolin Return) Motttier(explain under'g I
down the well
4.Darr%rll(sl abamlonrcd: 6-19-24
Sa.Well location: (��� 3 1 20P
Chemours
Faon7in t r,. Facility MN Wippikabkl t�F
22828 NC HWY 87 Fayetteville, NC ✓ /.��~ 6/24/2024
Ph,sisal Address.Cm.red Zip S aiwc ar('enifitd Wen('01cowtat m Well(Miser Dofe
Cumberland Bv wXsmrd thn form, I hereby certiA-tlru the we/lfsi was(were/ab andawrd in
1'a.cl a ii No (PINT turoruhatce with 114 MCAC O.N'.0100 or X O:OO Well Cons(neliun Standards
and the o cniny of this record laic be-cis protwited to dre well owner.
tb,Latitude and longiturk•in tleirivry minute u%conds ar decimal degre <:
(ihrelf fitekl.on.tau f q:n.,iffi.<:: 9.Site diagram or additional%ell details:
You ma% one the back of this page to prmide additional%ell site details or%ell
1 W abantdounictu details ti'ew Inay abo atach additwital pctgcs it iuecessan
CONSTRI ION DETAILS OF W ELIASI BEING.ABANDONED SUBMITTAL INSTRUCTIONS
act!.urafruJmu rr,.,rrd c:t; MMII. -
MePs ONL1r',lurk rlw.arme u»tarrili rune,✓rwr,k,rrsirnr um c.nt whmir.urr.N,rm. Ma. For All W dlv Suhmit this form %ithm 1,0 days of completion of uell
62.W'eB IDar:
PZ-42 ahandonnicm to the follmtiRg
Di%Won of Water Resources•Information Proceming Unit.
Ms.Total"ell tkpdu: 9 (ff.l
1617 Mail Senice Center,Raleigh.N('27699-1617
IOb.For IniacUon Wells: In addilicnu to scnduug the form to ilk address in llla
fi,,llorrimde diameter:1 Iin.) abu-,c. also sibnut one copy of des form%ohm 111 days of completion of%ell
abandonincnl to the tollounm
Di%Won of Waler Re.iiurcc%,Underground Injection CarIrVI Program.
led.W'au r kv el below QIYIrIwI W rfarC: 0 (ft.) 16.111 Mail.Scenes('earn•,Raleigh.N('27699-I636
4 Inc.For W'atcr Sunuh & leieetiun Wells: In addition to sending the font to
(.c.tArtercasinglcitphlifkinwnl: (�1 the addressiesi %Dune. also suboul one copy of this form %ithm to daNs of
completion of Ndl abanMmnent to the counli health clepartnieit of the couray
61'.Innrrcasinx+trbieg kn>,Kh(if lmovtol: (h.► %here aharwioncd
6%.Screen length lif hno%nl:5 Al
Fomi GW-9n Non Carolina DcpanInca of Em ironnicia aid Natural Rew>uacs-Dh isron of Wier R,,uuic,_, Ito iced Auguu:ol t