Cumberland_Well Abandonment_20240731 (2)

WELL ABANDONMENT RECORD For trlcmalVcONIY
lltis form can be used for single or multiple%ells
1.Wee('estractnr Infornn4tion: W'E1.1.ABANDONMENT D1TAI1 ti
Tyler Brown 7a.Number orwc•Ils being abanduned: 1
Well C'onuacior Nanw for well owner personally alunhuung well on lusrltei progeny i P w mlJaJdc aileth,w w ,«w-v,ife, siggd% IrrNs ONLI rerh tux• umnr
r,Nl,teal/lr Nl,/l+,llN/•NINIt Y1/1•rr,r,rll•NlY11J/rNl. F,rNI
4625A
7b.Alrpmtimate iolumc•,if%alir rt•maining in wcll(vlp/A (gal.)
NC Well Cbnlmanr Cerif"1011 NantICT
FOR W'ATER%11'PI1 N%FIASONIA:
SAEDACCO
Congatn Name 7e'I\Ire u(disinfectant used:_
2.Wdl Ceustrtiction Perndt t(:,
Liv idl q?y4krthlr well perlmtr u.e-!,wntl..ti'LMa•.I onowe Lgrll,n.el, ,f A men
lads Amount of disinfiYtAnt uxvl:
J.Well use(chnic well"w):
Water Supld}Well: 7e.Sealing materials used(check all that apph):
❑Aprwultutal ❑MtmrcipalrPubla iII Ncat Ccmcni Grout n Rcrronuc chips or Pcllcts
❑(;rnthcrtnal IHcamk Cooling Sirpph l ❑Rcsiderata)W'atcr Supph (unglcl ❑ Sand('emend Grout ❑ Dn(la}
❑hdusinaUCommercial ❑Rcsidottal Water Sripph isharod) ❑Conwtete Grout ❑ Drill Collings
Olrti •uun ❑Specialh Grout ❑Gracel
Non-Water Supple Will: ❑Benionde Slurn I I Other wNplain under 7g)
19htuouorng ORerusen
Injection Well: N For each matet•ial wk-ctcd abosc,prinide amount of materialsvoed:
❑AquiferRccharge OChoundsraterRenwiliation Neat Cem.:941b ,Wtr:8gal. Sand Cem.:lb ,Wtr:gal.
0.4quiler Storage and Recosen OSaillim Damer
❑Aquifer le-A 0Slonn%acr Drat mge — --- ----
❑Espennienlal i eehnolog\ ❑Subsidetre Control 7g.Prmide a brief description of the abandunnicut ptoccdurr:
I.IGcottr:mcd 1Cbscd I.uupi I.ITr:tur
poured grout mixture into hole
I IGcothcmt:d tHea tiny+Cooling Return) I I(hhcn{c\ lam under'g)
i.Datewrlhsl thandnnrd: 6-17-24
St.Well Wcation:
Chetaours ��►_'� tad(
Facilm?Owuret Nam Facility II)N(if applicabk)
R.Crrtiticatkwr:
22828 NC FiWY 87 Fayetteville, NC
� 6/28/2024
�'b•,,.el lalar.., c n.._,a1%,,, Su Wturnf('eerfrcd Well Cmuractai or Win Ow er Date
Cumberland Rt .signing this hlrm, I h,rebf cerlify that the wellfs►was(%err,atitucrdottcd of
u n Pancl Id:w,t :itba No (PtNi acc•onlatu e u tilt l9.a t('. C a2C JP100 or:C 02W Rill Cwtstrntclum.VINldtmis
and that a copy of this record lwav been privtwktif to the well owner.
Sh.latitude and longitude in tlegritrv!mimitrs,seconds Ile devinial devrers:
(it wcil fa41 ow Lot king t%s ulrkrer.i 9.Site diagram or additional wall(k•tails:
You mas use the back of this page to ptin ide additional%ell site details or%ell
N W :nbandunotett details. N'ciu ma} also atlach additional pages if occ:essan
CONSTRICTION DETAILS OF Nit FTIAS1 REING.ABANDONED SUBMITTAi.iNSTRUCTION$
.rthAit Nai!arntVn,aJr:nJ retold, 7 a,,u.'�J.',!a •!r,vJl:llj•ia'rn.iah.�Ir�u,r•n d.,ra�- ng•pil
vleldr q:YL1'Ilorh the sonar tr+mtMl n,Nr IJLm•hnxllrnt vxi cam.ul•mlt none hrtm lua. For All W c1ly Suhmti lilts fomi %Rion 30 days of completion of%'ell
6a.Well 111+r:
SMW-08 Aanilounient in the following
Dis ision of Water Resources.Information Procesving I nit.
1617!Hail Sersicr Center,Raleigh.NC 27699-1617
ub.Tntel"ell depth: 31 tft.1
1pb. For InieeNon Wells: in adduion to seidnrg lite furor to Ilse:ddtrss tit Itia
abo%c- also submit one cops of this form%nlnti +n days of complaion tit well
uc.RIIrcluilc diarticter:2 lin.l abandonment io the tollownte
rid.W arcr k•srl hrlii% �iiivnd%itrface: NSA Dicision of Water Revources,Cndergntued Injection Coutrul Pregrtrn.
(ry') t636 Mail Senice Center,RAkigh.N('27699-1636
10c.For Water Sumnh Ai Injection Wells, in addition to sending the form to
6c.Outer caunglendh tit lmown): th•) the addfessiesi abuse. also submit one copN of this form %ithin t0 da%s of
completion of%sell abanidonnicnt to[be cottm health department of the county
where aticindtincd
tad.InnercavinstuhinL k-nLth(if known): IN.)
tip•Screen lenLth(if kno%n1:10 (ft.)
Font GW-lu Nonh C•antlim Depuninen of Em inintlren and Nmwal Resowccs-Dis ision of Water Resources Rss tied August H)1 t