Cumberland_Well Abandonment_20240731 (19)

WELL ABANDONMENT RECORD Fog Internal UwONX
This form can be used for sinek of multiple Hells
1.Well Contractor Intnrnnation: WILL ABANDONMFNT DETAIL K
Tyler Brown 7a.Number of wells being abandoaed: 1
Well COrtlad0/Naar`inn well uw irr jVtxuull)AU11,1 hung wr:1 on 111S IWI propen)i Far w0firk ,nR'atnw .w wm-water srl7A hells ONLY rah Me .wit,
.•.n+rite,h.w,wti.r.u6wan(N ,.,n,an.uhnur wi. M1,rni
4625A
NC Well ConlmdnrCcrnficalinn Nan#icr
7b.Appniximatr inlnrwr of w anti remaining in rielllsli lgal.l
SAEDACCO FOR WATER SUPPI.V W'F.LI S ONLY:
Compaq)Name 7r.Ti pe of dimilifectam usrd:
2.Will Cei we(lea re rnk C
bo dl uppfk„r,i; weN lavwnlx o.e-('vrra)..S'lage.I ariame lnte,fum.ereA If Am,ra
7d.Amount of disinfectant uxvl:
J.Well use(check:well oat):
Water Supply Well: 7r.Scaling Materials used(check all that apply):
❑Aericultur it ❑MnmicnpalrPublic ® Neat Cement Gruen F) Bettonitc Chips or Pellets
❑(icnthcrriul tticangg Cooling tirrpph l 1311midcttial Water Supph ismglcl ❑ Sand(einent Gann ❑ Dn(tat
❑lndustrull'ommcrccd ❑Residential W'aterSupph isliarol) ❑ ConcrrteGroin ❑ DrillCultings
❑Irn •iwu ❑ Speciak Grout ❑Gra%el
Non-Water Supph Well: li Beraoiute Slom iJ Other(explain under 7g)
10hionnionnL ❑RecoSen
lejectinn%kill: 7f.For each material w ecteif Above.prinide amount of materiah owd:
❑AgniferRedurge ❑GroudwalerRemedimion Neat Cem.:94lb ,Wtr:8gal. _ Sand Cem.:lb ,Wtr:gal.
❑Aqutfer Storage and Recce en ❑Sabnn} Barncr
❑Aquifer Teat ❑Stonmtatrr Drainage _ --
❑Expenmeetal Icchtwloit% ❑ShcwdetreControl
7R.Pthide a hn-irf description of the abantiinment proci'rJun:
❑43cothenn:d(Closed Loop) ❑Tracer
Poured bentonite chips into hole to top of screen and poured
OGeothenint(Heaun •Coolie Return) L10dwrIexplain under' ) —
grout on top
i.Date w clivi l abandoned: 6-17-24
Sa.We11 iMatien:
l 424
Chemours
R.Certification:
r.�,ihi,gwntrNanr P.w.iln.IDNnfapphihk+ (ff.`3:.:ad�� 'r-�^yt�:.•�y �
13
•�Zl-���l.v gi..'Ci
22828 NC HWY 87 Fayetteville, NC ,�Ar 6/1(l/2024
Pin swat Address.(a),aid Zip St_ruitmc of Ceirified Well rbnrcxtor ur Well(lwwr Daft
Cumberland Bt mpung dur)F11'nk 1 hereby cerhA that the wellfsi was(were, ahwicho"ed nt
l'auit) I'.n.,1 Ilk llhi;:ueni No (PI%l acconhowe wA 114 NCAC OX.0100 or X 02(Nl(e'A Conrh•uehun.\(an(ktr(A
and them a a7M of sks record ham beer pru ided ro the well owner.
. Latitude and lnngittirk in d►greea/minuicalaccondt or decimal dtygnrs:
(if well frld.ow Lit Intig n mifliocint 9.Site diagram or additional well details:
N on m:a tic the back of this ptige to pros ide additonal cell site details or hell
N W' abado0nietn details. You nnai also attach additional pfiWs it iK•crssan
CONSTRIA TION DETAILS OF WELI.(SI RUN(.ABANDONED SUBMiTTAi.INSTRUCTIONS
.ifGAk wcfl,,,a0rU,h i m—&v it o,w1dq,•. 7.v rnrunyl.ulja•a lion rw rY,n-w.ilar w ,/r
we11r 0M.1 with the mare uwnlrer,rmar utiarnknrmm�t lour can v,hmi7 rare•k.rm. Ilia. For All Wells: Submit ih« form within +0 dacs of completion of ucil
6a.%%cll IUa:
PZ-33 ah:ndonmcm in the followu;
Diti%ion of Water Remmrcm Information Procr%,ing(.nit.
ob. total will dcpgoc 17.5
1617 Nail Senice Center,Raleigh.N('27699-1617
' lft)
lob.For laiectiee Wdlr: iu addition it.,seidme the(unit to ilk addtess to 10a
abn\e_aluo submit one copy of this form NNnhui 10 dins of completion of well
er,R,irrliirlr diameter:2 kin.) ab:uidournam to the follow me
Disisiwe of Water Rewiurces,Underirnand Injection Control Program.
bd.W agar ky ti below Lnnarid wrfacc: 6 (ft.l 1636!Nail%eniee Cemrr,Raleigh.N('27699-1636
(ft 1 If1c.For Water Sutitih A Injection Wells: in addition to se ding the form to
tic.Outer casing length Iifkuown): the address,esn abane. also submit one cops of this form within if) days of
completion of well ahandnw»crn to the counh health dcpartmn i of the coum
where &i dnncd
bf.Inner casin�'robing knLKh(if Mnw n is (ft.►
6g.Scrccn Icnygh or Mow n 1:5 (R.1
Fomo GW-ati North Camlim ikpannicut of Eris irnnnkra aid Natural Resource, Dh isnn of Water Resoiaws Res ised Aupu Sii i