Cumberland_Well Abandonment_20240731 (33)

WELL ABANDONMENT RECORD Fot,tacrndLsct7Nt1
This form can be used for single or multiple wells
1.Well Cnetractnr Information: W'ELI.ABAVbONMEN't DETAILS
Tyler Brown 7a.Number of well.being ahandom:d: 1
Well C'owracsor Nam tot well owner petwfulh alun6ttntig s A on lit,la 111o}xes i it widnr•h aile,lxw W' ww.oater sxjyA refli MVLV verb llx• sWxe
.,Hn ma bwt rrhJ.ehnrnxm n.x,.w.xhwrt w..F.rm
4625A
?h.Approximate ruinmc of watts n•maininx in Arll(3ijV/A (gal l
NC Well CoamctorCentfteanoti Nanibcr
SAEDACCO FOR NN A'rE R S UPPL 11N F I A S ONLY:
CotRam Name ?c. I y,x•of di infectant tried:
2.Wdl Cmdrairtiea Pet•nit ill
List 41 cggAtvblr well pt•renix u.e.,uxnrr.S1,fie.)an,ume torte ifnn.r/r..r1 Amrrrr
7d. lmrrunl of disinfectant uxd:
J.W'dI use(check wall mw):
Water Supply Well: 7e.Sealing materials used(check:all that apply):
❑Apnculniral 01NunicipaLPtlblic M Neat Ccmcnt Grout n Acntonuc Chips or Pellets
❑Geothermal(1eanng-Vooling Supply i ❑Rcsidennal Watcr Supph ismgle) ❑ Sand Cemern Grout ❑Dn Cla%
❑ltid11SRUl('ommercial 011midennal Water SuppN I shared l ❑Concrete Grout ❑Drill C'uthrip
❑hrn uoi ❑Specialty Grout ❑Gra%cl
Non-Water supply NNr11: ❑BerntoniteSlum LI Other(explain under',.V:
Iflhlonitonng ❑Reco-,en
Injection Well: X For each iumriial%cl cicel shove,provide amount of material.rand:
❑AquiterRecharge ❑(inaudwalerRe ivied uuion Neat Cem.:941b ,Wtr:8gal. Sand Cem.:lb ,Wtr:gal.
❑Agutfer Storage and Recmen ❑Salmin Barnet
❑Aquffrr Lest ❑StonmsalerDrantage —
❑Expenntental IechnoloAx ❑SibsidenceC'onrol
?>;.Pnividc a brief dcscriptino of the alwntk,ulncnt pnrccdulr:
LIGeothennal(Closed Loop) UTracer
L(Geothermal(Healin 'Coolie Return) UOthcr Icy ain under 7 ) poured grout mixture into hole
1.D•att wclhr)ahandnocdc 6-17-24
ia.NNrll lucatinn: '
Cheamours
Facilatr�Otsf>Gt ti.�rr Facility mw(;fapplicabk) R.Cet'NfkaldttR: 6Yl.i;„$
22828 NC HWY 87 Fayetteville, NC „� �~ 6/18/2024
Ph,steal Addrev.(its.and Zip tit_iultuc orCeniSed Well('otariclai or Wcll l ht txr Dme
Cumberland liti -vig inn din)blurt, I hereby,cernly that der wellfxi wdx(were,trlknf k,ned fit
n I'n,el Ideadkyilon No (PIN) arronki nc'e with 15.4.NC-IC 0'411100 or X 000 flesh Cvnxtrw('1u,q.\t,rn(Aurdr
and that o cop}of this record hm•been immided to dre well owner.
Sh.Latitude•and hutgitudt•in dtgrrrNminutrrt.ccnndr tit'decimal di-grew
lit ucH frcld.Otte L1t long P wifficwt1) 9.Site diagram or additional well drt0s:
You may tic the back of this page to pro%de additional well site de(ads or well
N W' abandonntera details. You ntay alw attach additional pales if necessan
(Y)VSTRI( IION DETAILS OF NN E:LIA,I BEING ABAN DON :1) SUBMUTAL INSTRUCTIONS
.uJ.0 u.�:ru,lair ma.r,h. i J,WiLL�rla. :'..r 9al:Oj•i.-:)i. e......v rr,n n,i1ar wq•!r _
olrlhO.YL)'rMrth ibe+rxnr omit..,tnk ranr,NJtxA•mmriii inn can,Uhmil,otr_lornr. Ilia. For All 'AdLs• Stdrnut (her form within +0 din's of complewn of well
4.4,Well IDd•SM-06 abandoinucn!In the following
Die irion of Water Resources.Information Processing Unit.
1617(tail Senicr Ureter,Ralen.h.N('27699-16L7
6b.Totel well depth: 22 1(1.)
l(lb.Fur Initction Wdls: lit addition Iu selaling Ilk:forth to the address in loa
abotic. also sidtntit one copy of dos form within a)days of completion of well
err,Fkm•hnlr diameter:2 1in.) abandonntem lit file followrti¢
I,&NNatcr k•rt•I brhm 'nrund millavc: N/A Disislon of Water Resources,I. ro ndergund Inimtion Coulrol Program,ogra ,
(ft.l 1636 Mail%mice Center,Raleigh.N('27699-16,I6
Inc.For Water Sunnh & Inicctiire WAs: in addition to sending the form to
6c.Outer casing Icnxth tit Mow n 1: tft l the address(es1 aboee. also submit one copy of this form within 3n days of
completion of ssdl abandoruncm to,he courtly health department of the coum.
(of.Innrrcasing+tebin'Icn�,th ii(I:nnwn wlKtc alt:tndoncdi= eft.►
6g.Screw lerl Iif(.nn.t n 1:10 (tM l
Fomi GW-tn Noah Carohni Dep rimca of Ens frolunera and Natural Rewfaces-Dh ision of Water RoOurea s Res ncd Aapur 21)1t