Cumberland_Well Abandonment_20230419

WELL ABANDONMENT RECORD For lrticmrlvscONLY:
This form can be used for single a mldtiple wells
A.Weli Contractor Information: WELL ARANDONMENT DETAILS
� i
Scott Hunt, Jr 7a.Number oftrells being abauduried: 1
%lelt•Calweler Name(or well Owner pctsoldily abamianlrrg uall an Wier prapenv) Fcv tetrlople lnleruar a• twri itirarer supptY wells ONLY' W11i Mw sti.•ue
eac;mrcnon;�,arre(r�u„��rr,ie,n erne sr,hruf wicforrn.
4561-A
NC Nell ContradnrCcrtifrcalion Number
7h.Approvnimte volume of crater remaining;in wellwo ( rL)
SAEDACCO Inc FOR WATE:RSUPPLY WELLS ONI-Y:
Con�any Namc 7e.Type of disinfictant used:
2.Well Construction Permit l#:, ,
Ltvcall rlpplkubie wellpenritr(i.tt Ctnr&,Sw,,� ,!'adam-e.hIg-Ewat",rlci ff ww•tt 7d.Arnuritit Of tllilnfecttwt uSwl
3.Well use(check well use):
Water Supply Well: 7c,Scaling materials used(check all that apply):
❑Agticultarat QMtmicipaVPublic 00 Neat Cement Grout 11 Bcntonitc Chips or Pclicts
❑Geotherm t(HcatinglCoolino Supply) ❑Residentiht lYatcr Supply(simple) ❑.Said Cement Grout ❑Dry Cyty
❑IndustriallCotnmcrcial ❑RcsidentiA Water Supply(rihatuil) ❑Concrete Groul ❑Drill Cuttings
❑Uti •tio.a ❑Specialty Grout ❑.Gravel
Nort Water Supply We11: C1 Bentouite Shiny ❑Other(e-r-plainunder 7g)
�hlouitornre ❑Recovery
Injection Well: 7f.For each in3tcrial selected above,procidc amount af.mtrteNals used: .
❑AgttiferRecbarge ❑GrounduvierRentediatian Neat Cem.:941b ,Wtr:5.2gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage anci Recovery OSalinity Barrier
❑Aquifer Test, ❑SlornovaterDiainage
❑Expetiummial Tochuolog-v ❑Subsidence Cottunl 7*Prnoidc a brief description of the abandonment procedure:
.❑Geotilemral(Closed Loop) ❑Tracer
Tremie .grouted from bottom up
❑Geothemtat(HcnttMCooli»y Return) ®Other(ex lain under 7rt)
4.Date well(s)abandoned: 3-06-23 �,.,.' le 1--I_.
So.Well location: APR 1 9 2023
Chemours
Factlit?tDtvtt<rNumc. F ilia s( ) R.Certlllcatlon: Irt`,c �<s>:'�sa ?ran 3 ,Hno
ac ID ifappl-vablc ;;i.,II••ll
22828 NC-87 Fayetteville, NC 28306 ��'idL,L �GCyGt� �/L+ 3/19/2023
Physical Address,City,and Zip Sigrimtrc orCert Mcd tVOI Con ,tor or Well owtur Dille
Cumberland 1J)r skq;9gg lhi-v form• I bemby certify that the well(v)teas(urerg)abandoned in
Couatj• Parcel Idon1ifL61bu No.(PIN) atxvnitince will?15.=I.1 CHIC 02C.0100 or 2C.0200 hell Consintclion Staruktrris
and iknt a copvoftlris record has been provided to lire well owner.
5h.Latitude and 16119itude in degircestrulnuteslsecoods or decimal degrees:
(if twit r44,arse 4uitong is tnMcieta) 9.Site diagram or additional well details:
You tuay use the bae•k of this pag,e.to provide additional waH site details or well
N W abandountetii details:You may also attach additional pages if rheeessary-
CONSTRII(-TION DETAILS OF WELU,%BEING ABANDONED SUBATT7TAT,TNSTRUCTIOYS
:Pftrulr tie!!cnrrtrttclian n!cvr�1/s1 lj atrcllwle for multiply idfeirien ar rr�a•untcr supple
hell ONLY u•ltb fi caw subtteil are fatnrc Ilia: For All tVelie• Submit tltcc font within 30.days of completion of melt
6a.Well IDS:PW-10R
ibanilonnicrit to the following:
Di.'isian of Water Resources,Information Processing;Unit,
6b.Total wcU depth: 67 (ft.) 1617 Afait Service Center,Raleigh,NC 27699-1617
10b.Dr•Tri eetlan Weals: In addition to sending the font to the address In l0a
6e.Romitole d(attletee:2 (iii,) aboaa,also subndt one copy of tlhis,torah within 30 days of completion of well
abuudotuttetq to the fallowing:
6d.Water level hcloct ground surface: 47 (ft,) Division of Water Resources,Underground Injection Conitul Ptngram,
1636 ATail Senice Center,Raleigh,NC 2 7 699-1 636
6r-Outer caste Ica if Imown)- (fur) 10c.Fnr Water Sumnlc•& TnieetlrrII Wello: In addition to sending the torah to
g ( 0
the address(es) above. also submit one copy of this four within 30 days of
completion of well-abandtnrment to the county health depa imcid of the counter
6f.Inner casinwtnbtngq Lengph(if[arawn}: 0 (ft.)
ss°hertz abctndoncd.
6g.Scmcn length(lf known):67-57 (lo 9) (ft)
Form GtV-30 North Carotim Depamncra ofPnviranment ad Natural ResamTes-Division of Water Resources Rcvi cd August 2013