Cumberland_Well Abandonment_20240731 (7)

WELL ABANDONMENT RECORD For ltaentalUnONLY
This form can be used for single or multiple wells
1.Wed Contractor Information: WELL ABAVD(lNMEN'T DETAILS
Tyler Brown 7a.'.Number of wells being abandoned: 1
Well Cotrtactor Nantc for hell owner pcn(ul:dly AU11.itnuug NrII on hla:llet plopetg t For ronlvtgir Ntmfttnt or rtcta-Muter snly4i .e Y, ONLt rrrh ow
c'.Nlf Nlr•rn N •Atirlrryh Nlplr`il(1.iM,rU1.N1411t1 rNle'(trrNl
4625A
NC Wcll ,�rllfiadtnr.Nnntut
7h.Approximate Nulumir sit'wahr remaining iu wdl(s)1 Ityl•1
Cnnlr,rtnt f
SAEDACCO FOR%%ATE R SI'PPI.Y WELL ti ONLY:
Cowl Name 7c.TN loc of disinfectant used:
2.Wdl Comerta tion Permit M ,
lnrrdl qutfllafttlrwell perwit%n.e.I'trfonn.SIINr.t ana-e• Inx,Iltfrt.rh i/A:rnrrrJ
7d.Amount of disinfLCtAnt u.%td:
3.'Artl u%c(check well use):
Water Supply Well: 7c,Scaling materials used(check all that apply):
❑Agmulturd ❑tihtnicipil:Public M Nau Cement Groot f7 Bcntonitc Chips or POWs
❑(kothcrtn;d(HcatmG('ooling Stipph I ❑Rnitktat:d Water Supph tuncici ❑ Sand Cement Cirout ❑ Dry Clay
Olndustnal:Commercial ❑Rcstdctvml Water Supph islmred! ❑Concrete Grout ❑ Drill Cuttings
Elltrigativii ❑ Specialq Gtuut ❑Gomel
Non-Water Supph Wed- U Beraorute Slum 1 1 Other 4explain under 7g)
®Munuonug ❑kau%en
In jectinn Well: 7t:For each material wlected ahow.prn%ide amlit at of material.owd:
❑AgnderRecharge ❑GmundwaterRenrediattat Neat Cem.:941b ,Wtr:8gal. Sand Cern.:lb ,Wtr:gal.
OAgmfer Storage and Rear en ❑Sahnill Lumen
❑Aquifer Test ❑Slommaicr Drainage
❑E:Ippenennental Ie+chnology ❑Subsidence Coraml 7g,Proti idea hricf dexriptinn of the abandonment pro edurr:
OGeothemtal(Closed Loopi []Tracer
Poured bentonite chips into holrbt to t°' of screen and poured
OGeothenml(Heaun 'Coolin Return) OOther(explain under 7 ) %- it-..' v
—`-- ��-�
grout on top
4.Date w (s)Shandoned: 6-17-24 JUL 3 1
3a.Well location: !fI`3'FF L'' t r��y ' U91A
Chomours `�•� '
Facilit%(1-. .1•<.,„ F.W11TI, ran 1(ifaDelicabkt 8,Cetlifkalion;/�.-�y
22828 NC HWY 87 Fayetteville, NC ' / 6/18/2024
Ph.soul Addreu.C,i..and Zip Sr adtnre of CenIikd We It('a ninctai rat W1:11 Ott rcr D:ae
Cumberland 13y,.vjgmtjg the%Joan, I Immby certtllr that the mrell(s) was(it ere f ahevikned tit
Couuq Patut Id,u,fec:nww No IPI\1 arx-arrho a with 13.4.V('AC 02C,0100 or 1C 0200 Well Construrhen,.S*w(4trdx
mod that a crpy of this record liars been pravu ed to the h ell owner.
Sk Latitude and longitude in dcgmewminatteslwainds or decimal deg_once:
(ifwetl fcl1,ow lavlong is NttfTtctertt) 9•Site diagram or additional well details:
You mac the the back of[his page in proi,ide additional well site details or%Nell
N « abatdunnncni details. You uta% alw allach additional poles if n ecessan
CONS I R1( IIO` DE(AILS OF A E1_l.(S1 BEING ABANDONED SUBMITTAL INSTRl1MO NS
.I(tfxlt nri!evfr:..rrm hart nufrds+{1 w wlw4k•. !vr fruJLpic ufrec Uafr fr rrfn-e-uta7 sapyfr � _
w rflsONLY wuh rhr evmr(tur..rrYf rt nr rtAwr<knNflrrtr.rue can ah art ate Nrrwr. 10a. For All Welly Submit Ihts form within 30 days rat'conrplClran of tell
6a.Well IDO•P2-34 abandonment In the following
Di%isina of Water Remiumm,Information Processing Unit.
6b.Taal well depth:Ier. 18.5 1617 Mail Smicr Center,Raleigh.N('276eN)-1617
[n.)
10b,For Iniedion Wells: to addition to sending ilk form to the addnrss rat lua
(w.Borehole diameter;2 [in•) aboi c. also submit One copy of this form wnhin 30 days of cumptol on of Hell
abandonntenr to the following
Di%ision of Water Remurces,Underground Injection Control Program,
6d.W'ah r k%rl hrluw l(IYIa1NI W rfael': 6 ft.) 1636 Mail Scniee Center,Raleigh,N(•27699-1636
Inc•For Water SuatI & InitYtiin Willa: to addition to sending the font to
6r.Outer casing length(itknewU: OIL) the addrewes( abo%e. also submit one cops of this form NNilhin fir days of
completion of well absnlormxnt to the county heath department of the coum
6f.Inner casing/tttbina>:keglb Of hsown): (h.l where ahindoncd
(tg.Screen length 4if lino"n1:5 (h.)
FontGW-3o North Carolina lkpanutcn ofEnt troontera atd N;uurrl Resonrees -Di%(sianof WaterRcsonncci Re.tied Aapr%r 2011