Cumberland_Well Abandonment_20240731 (32)

WELL ABANDONMENT RECORD fotlrikfn Ig-s01,11 Y
This form can be used for single or multiple wells
1.Well Cantracinr Information: WELL ABAVbl1NMENT DETAILS
Tyler Brown 7A.Number of wells being(abandoned: 1
We11 tl-rdrackn Name iof well uwirf persarulh abasolnnug well cnr his her puyi.gi i r,v mkJbph og,vom .v wo- aer .kjyvi -df, OA'LI, -A I&- wimr
uMl�Irm<tJ,M,„1ti,ukkWpk Yir.Wm NW,mhm/f,m.ir,rm
4625A
76.Appn
NC'Well Carrmdat feniftc ilinu Now hi: nsimAtC rolerne of water reynainhalg in well(sf/A (Val.)
SAEDACCO FOR N ATE R�VPPLW WHLIA ONI.W:
Cnn p ni Name 7c.'1'y Ire of disinfectant used:
2.Well Comstr uctiun Permit 0:,
bst mdl s*-jio'avble ire1l perwiliv(i.e.(,.WM.axe.I unawce lnteiimim it.,if klm, t
Jd.Amdwnt of disinfCCtAat uxd:
3.Well use(check hell use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Apixuhural ❑Municipal,-public ® Neat Cement Grau ❑ Bentonsic Chips or Pclkrs
06cothennd ftangWCoobnp Srrpphy l 01taiukraial Water Snnpph ismg1c) ❑ Sand Cemom Cirout ❑Dn Chy
❑hdusinal:Commercial ❑Residential WatcrSuMh isharod) ❑Concrete Gram ❑ DrillCulings
❑Im •till ❑ Specialh Groul ❑Crawl
Noe-Water Supgils W'Cll: ❑Bentonne Slum U Other lexpiain urder'',gi
®Mouuonne ❑RCCOocn
Iniettinn Well:• 7f.For each material tlektted abowr prostde amotot of mater'iala owd:
❑AquderRecharge ❑(imufidisanerRenredimioti Neat Cem. :941b ,Wtr:Sgal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Sioragge and Recm en ❑Saluun Hamer
❑Aquifer Tes( ❑Slonms:ncr Drainage -- ------
❑Expenmemal I clmolotn ❑Substdclice C'onarul
7V.lrtride a hricf drscriptinn of tM:abaotk+ninCnt pnrcnlun•:
UGeothemul(Closed Loopi ❑Tracer
poured grout mixture into hole
i IGeothernial lNeatin -'Coolie Return) 00theric\plain under 7g I
A.Date en elh i l abandoned: 6-17-2 4
;a.WYII IIKatkln:
Chemours -
S.Cenificatilan:
Fac ilrry:Ou trio Name Fxilar fDN t if applicable l ..
Ir v:xw.0 Tr. SoNi t t
22828 NC BWY 87 Fayetteville, NC �f11. �L7 6/18/2024
Ph,skill ad(INM.Cn,,srd Zip S141trrc of C4:fnrlkd Well('nnrracsor w Wen 0"noir Dare
Cumberland Ii') s1Xiurix thn form, I heriebo�•cerh# that the wellfsi was/were,ubwlJnned ur
t',uurn I'�i:a lokfli,tr.iikm Nu IPINI rutvrthntre with 1JA.WCAC 0Y'.010f)or Y- OYM Well C onsh horn St(mdUrds
tmd thta a aapy of this reoroM hat been prm-mW to the well droner.
5h.Latitude and b+ngitutk in dcwvvvminutr%,wvinds nor decimal dtgrieea:
nil ncll fold oils:lat.Whig a.srdltcwtfil 9.Site diagram or additional wall details:
You may use the back of this page to pin do addrtlotlal well site details or weU
\ �1 abandlnnnitcia details You ittio alw attach additteintal pages if riccessan
of OV,I RI of 1101, DETAILS OF W ELLOi BE]NG ABA\DON ED SUBMITTAL INSTRUCTJONS
Ilb .,. „r rr,ord,�:1 ;,wh,k• 1.v to mp., :,11.o1,r,,.r,r•n echo w7,h -/
+�LV oA the wmrtvmr+v,f+,uruhavkwmvii +.weonz h,mr.oreA•,rm Wa. For :►II 1\rtb: Sabina this ford wlt`!n V dais of completion of well
oil.1�cll I Iles SMW-05 abandonment In ttic follmcing
Disision of W Ater Resr+arcts.Information Proces:arlg;Unit.
Total wCll dcgrth: 20 1617:Nail Service Crater,Raleigh.SC 27691-1617
6b, (ft.)
10b.For Iniox lon Wcils: In askluaiu to smiling ills form to ilk address nn lua
abo%c. abio snbnut otnc copy of this form%what ;n days of cumpinion of sell
6c.Ikrrrhoic diafnctcr:2 (hLI, abandonment lu the tollounie
6d.Water krrl below .-round wrfa,c: N/A (ft.l Dhision of Water Re"urces,Lntkrznmod Injection Cestrul Program.
1636 Mail Scnidr('cater,Rakizb.NV 27699-16M
Inc. For Water Supoli & Inkction Wells: In addition to seeding the form to
br.(hirer casing,(coldly iH knonnC lf�l the address(esi abote. also submn one copy of this form Witlhn 11) days of
compldron oil Isdl ab:udormtcnt to the coum health department of the courtly
W.Inner casin-_,ro' binL length(if know where abandowdn):
(,-_.Scrccn length lif knuwn):10
Forst GW-an Nonh('amhtn Dcpannwrt of Ern irofnnefo aid Nanutal Resources Dn isr.in of w'awf Resources Rn red Angus 2)1I