Cumberland_Well Abandonment_20240731 (31)

WELL ABANDONMENT RECORD ror Intermit Use ONI1-
This form can be usw f,•r single or multiple wells
1.Well('(inn•actur Information: W'FLI.ABANDt1NhIFNT DFTAIL
Tyler Brown 7a.Number of s►t•Ils being,abandoned: 1
's,ll t. •waam hang ter well uw n'T pcnanulh alxslt110uua;•well on havltet propcm t hw w0fol-le otµ•t&ur ,w ,ww-+ore, smif4i •rib O.NLI -eth Nn• „we,
t,Nl�mrft rlNr rthil,kh Nlpl,Ylr.I,t!,rUl,Nl`Ifl;1 iNrr'M1,rnr
4625A
71).Approximate%Metri of watts•remaining In wc11(,IN/A fgal.l
NC Wd1 Camlmoor Ceti lftcatNan Nnnthci
SASDACCO FOR N'A TF.R SUPPLY N'F 1.1.S O N 1.Y:
cbnv tnl Nam ?c.l.lK of dhinfectant used:
2.Wdl Ceatructimn Pernit U:r
La all nppNcmb&well pormrh rl.e.Ccvoon.Mak•.I onar a ltyetixom,ek.+if beriwm
?d. -%Mount of disinfectant uxd:
3.Well use(check well utr):
Water Suppi}Well: 7e.Sealing material.u.ed(cheep all that apply):
❑Agiscultural ❑Mtmtcipil;Rtblic ®Ncat Cement Grotu Fl Betaonitc Chips or Pclkns
❑(iconhcrmsl(Hcanng'C'ooling Stt*i i ❑Kcsidcrsial Water Supph isnnglci ❑ Sand Cement Grout ❑ Dn Clam
❑Indusirtal:Conmtercial ❑Rcstdctstal\Water Supph'tsiutrcd) ❑Concrete Grout ❑ Drill Curling%
❑ltn •troll ❑Sp cialh.Grout ❑Grasel
Non-W ate►Supply Well: ❑Bentonite Slum U Other(erplaia under'gl
QOMonllonng ❑Rccomen
Injection Well: X For each material w1ccttd abuse.preside anutuef of materials used:
❑AgnNerRcchargc ❑CiroutdwaterRentcdiation Neat Cem. :941b ,Wtr:8gal. Sand Cem.:lb ,Wtr:gal.
0Aqutfer Storage and Recin en ❑Saloon Barrier
❑Aquifer I'est ❑Slonri mater Drainage --
❑E.mpertmemal Te>hnolot ❑Slbsrdertr C'onarol 7g.Pros ide-at brief description of taw abanthlnincat procetluty:
❑Cteothemral(Cbsed I,00pi UTracer
poured grout into hole
❑Gcothemsal(Hearin +Coolie Return) UCAltcr ic\plain under' ► _ f
4.Date well(%)abandoned: 6-17-24
Sa,Well location:
Chemoura
Facilih,Ytn over NaForte 8.Cenifkadon:
22828 NC HWY 87 Fayetteville, NC ,/f5 6/18/2024
Ph,skal lddrev.(tN.and Zip S entire of Cend'xd Well Contractor tit Well O%xcr Dare
Cumberland Ili sixturox this form, I hereby cerfi#thin the well(s) was/went catiurnknied in
t'annl. P.n..l ld.uol:.,ntnu ti„ :Ply 1 ar onhriu-e with 11 mr.-ir ox goo or x, 0?tp Rill Cirn.rinictutn,Vttruktrdx
mid lhal o mpy of trrs record has been blot ukd to the well owner.
Sh,(attitude and longitude in nkytrsrw'minutrst.etsnuls mr decimal deer cs:
01%ell f0d.one L•rt.lmtg N sttlfinettt 9.Site diagram or additional well di-tads:
You Ina% the the back of this page to ptoxide additional well site details or well
N N abandtn meta detail]. You niam also amtach additmnal pages it neccasan
CONSI KI( PION DE'tAI1.S OF NE l-lasi BEING ABANDONED SUBMITTAL,INSTRUCTIONS
.df,klt aall turaJratla•,t n•nrt,ha'11 of wl,Pk. 1'.w mulapi oyaaa!ut,w oat-n,11ar wltph
mr11xOALYmirkalit.uutrccvn+nrtrwn a4urr<k,mntrmciomcaawhmlrnlre/toll 10a. For All Wcils: Strhmtt this font within +0 days of completion of well
6L Well ID/:
PZ-17 abandonment in the following
Di%Won of Water Resources.Information Processing Init.
6b.TealslsddefMb: 26 —(ft.) 1617 Moil Senice Center,Raleigh.N('27699-161?
Ittb. For Imleetiom Wells: In addition to setdutg the form to trite:ddncss tit 103
alo me. also subinit one copy of tins form within 10 dins of completion of well
6e.BereMtle diameter,1 fin.) abandonment to the following
ad.Water kcal hrhlw "round surface N/A (D 1 Di%ision of Water Resources,Cndergroved Injection CotNrol Program.
1636 Mail Semite('cuter,Raleigh,N('27699-1636
Itic,For Water Sumnh & Initctkn Wells: In addition to sending the form to
6c.Onto casing len--rh lit Lnow n r OIL) the addresses) aboxe. also submit one cop} of this form within to days of
completion of wdl abandonment to the count health department of the:ounh
wlscrc ahandottcd
bf.Inner caring to hin,�len•Kh.it Lnoma n is (ft.)
kg,Screen length(it kiwi n t:5 (ft.)
Fom GW-90 Nonh('amhra Depannscm of Em truninera aid Naimmi Rcsowccs-Ms ision of Water Resoutees Rc%scd Ampu 21)11