Cumberland_Well Abandonment_20240731 (6)

WELL ABANDONMENT RECORD For lnaeml Use MIA,
This form can be used for single or multiple Hells
L\\ell('antr•actnr lufnrsultion: W'EI.1.RBAVbONMENT DETAII S
Tyler Brown 7a.Number of well%bein(;ahanduned: 1
Well C'onuacior Nana lot well o%ni persctttally aturdomng well on hn9tcf propM t Flir malfrph otlethrur ,w nnN-oater stggdt rrff< (/\(.1 rrrh 14, aYnr
r„Avfrttr fJ,NI,1ltiilrh/INlnlr-nf.1".1.01 IUNIIlf lot, 610111
4625A
'h_Appnnimate tolunic of water•rrmaininy in Arll(ai I19L)
NC Well Cmnr,�,1„r Ccnificalinn Nnnthn
SAEDACCO FOR W'ATF R S t'PP1.Y%%F.I.I c Oti l\':
t'nipiunl Wm ?c 1)pr of di%infectant n%rd:
2.Wdl Canatttaction Permilt M:,
List dl w#kubk well/,write n.r.Ciman.J7ure.I urturnce ltrrecnnn.etc.,,l4nuwn
?d. \mount of di.inftYtant uxd:
J.Well usr(check well use):
Water Supply Well: 7e,Sealing material.used(check all that apply):
❑Agmultural ❑FfimKipallPublic 2 Neat C'cmcni Grout fl Bctrtonnc Chips or Pellets
❑(icothcmial(Hcannrr'Cooling Supplyl ❑lkmdcraial W'atdr Supph tuncicl ❑ Sand Ceniera Grout ❑Dn clay
❑ludusinal,Comniercial ❑Residential Water S iMlIl isharcd) ❑Concrete Grout ❑Drill Cuttings
❑Irn••toll ❑ Specialty.Grout ❑Gratel
Non-Water Supple Well: ❑Bentonite Slrrn' I 1 Other(etplam under'.gl
(O lomtortig ❑k Lcof rn
ejection Well: 7f,For each material.clectcil Ante.ipn.itidc amitunt of material.aced:
❑AyuderRecharge 1JCirounrdaaterRerredialion Neat Cem.:941b ,Wtr:8gal. Sand Cem.:lb ,Wtr:gal.
❑.Arlurier Storage and Recoy.en ❑Salmih Harper
❑Ayurler Iest ❑SlornmaterDreuwge -
❑E\penniental 1 slhnologn ❑Sub%rdi ttr Conarol 7g.Ptnsidr a brief desc•riptinn of the ahamkininent pnwedurr:
I_u3cotitermal(Closed Loop) LlTracer
Poured bentonite chips into hole to top of screen and poured
I ICicothcrrral(Heatin 'Coolie Return) 11CMtcritx am urider'g) ----
grout on top
4.Dare wellt.)abandoned: 6-17-24 A
54.Nelllocation: JUL 3 1 2024
Chernours
FmilmlowncrName Facility Inr,dappla-ihk,, S•Cenificatititi: jr�o.7. �^f�a'r 4✓M:^'.�`t�l�
22628 NC HWY 87 Fayetteville, NC
6/18/2024
Pun steal %ddrem.(iI+.aid Zip Si6asive of Ceni9od Well Coufrict r or Well Chttcr Dare
Cumberland Ili'.si}purox this form, 1 hereby cerr/f that the wellfs) was(were, rrhatiukowd tit
(o m A, Parcel lddalrficatlnru No.W Ni acronlutue wille IJA WAC OX.0100 or X OXV Well C ovistrnrc6r,u.Stantlitrdt
and that a cony oJtkis record has been ptrovtaled to tke well nwner.
Sty,Latitude and longitude-in degrees/mieutes/scnindi or decimal degPpes
III wdll fakl otic W king t.snllicietai 9.Site diagram or additional well details:
You mat me the bacl,of this page to pan file additional well site details or well
N \\ abandonment details. You may alµ:dtach:ddnwitnal pages if tieeessan
<O ,I NI ( IION DETAILS OF\\ELIAM MEIN(:ABANDONED SL'BMITTAI,INSTRUMO'(S
110x8 .11;�, .�!�a,lr,.t rrrurdv;{J of wha',h• 1•.w mrJrJple uyn liner,v rwn r,llrr w/R,ir
rrlls ONLY link the tune rwrarrvn ra,n d urnkux,imr_t.n can uhmH rare N elf Ina. For all %06: Submit lion Conn within 30 days of completion of well
6a.Well ID+ti:
PZ-35 ahaidonnicnn m rile ft4I0,.%ing
Ditisitiu of Water Rewitrrci.,Information Prucrssing It nit.
61),Total well depth: 17.5 (h.) 1617 Mail Ser-Oce I enter,Raleigh.N('27699-1617
Itfb.For Injection Wells: lu addition to scidute die form to the address in Ilia
above. alµ subutit one copy of this fora wrlhm a0 dais of completion of well
6c.Borelwile dianiviler:2 lin.l ahadonnicnt to the tollowiue
IN%Wou of Water Rewturces,Underground Injection Contaol Priapam.
(id,W'atcr keel hclott fnwwnd wrfrrr: 6 (ft.) 1636 Mail Seniee Center,Raleigh.NC 27699-16M
fide, For Water Sunnh & Ink-tiinn 3YS& In addition to sending the form to
6e.Outer easing length(iflmowoff: (ft.) the address(esl above. also submit one cop} of this foam within fn dais of
completion ol'hell abandorunent to the county health department of the coum
6(.tnnrrcasin-_,-'tnlrinp kn>,Kh(ifl:nown):_(ft.) w hire.tha rdo ncd
6%.Scn-en Icn:ah(if ktlown 1:5 (h.)
Fami C,W-ii i North Cambria Ueparrnmat of Eat ironniera and Natural Resources-Dls ision of Water Resources Retied Auptsi:Ills