Cumberland_Well Abandonment_20240731 (8)

WELL ABANDONMENT RECORD For 1t"nialUscONLY
This form can be used for single or multiple wells
1.Well Contractile Information: WELL ABAVbONMENT DETAILS
Tyler Brown 7a,Vumber of liens being ahanduned: 1
Well Cotaracim Nance tar Moll uw net personally abandoning well on On het properi%i Frw mo/nt,h uliecl,wt ar ryNl-M(Ita'r sapp!% -ells ONLY -A Mk' ,vnr
tryl.Ir1/[Ilr MI,II,a1kh Nl Nlant.Irin r•ei,atr,rl;r.J,r h.r„r
4625A
N('Wc1lCammdnrfcHift;dtnnNnn%l+rr
71).Approximate xolume of%%at(e remaining in wrllool/A Isal.l
SAEDACCO FOR WATER SUPPLY WFI.I.5ONIA
Contpans Name 7c'I)pe of disinfectant used:
2.Well Construction Permit 0-,
List t,J1(,µrAwbk well pertntls d.e-(cmnn,SANr.I ariarce bromism.etc..it Am,wn 7d.Amount of disinfectant used:
J.%ell u.r(ched(w ell sine):
Water Supple Well: 7e.Sealing materials used(check all that apple):
❑Apriculniral ❑Mtnncipal:Aibhc ®Neat Ccmcni Groot n Benanav Chas,at Pellets
06cothcrm:d(HcaringJ'aoling Suplih i ❑Rcstdctrtal Watcr Sopph isinelci ❑ Sand Cement Grout ❑Dn(U%
❑hdustrial,Commcicial ❑Itcsidcrroal Water titipph tshared) ❑ Concrete Grout ❑Drill Cuttings
❑Lori •ion ❑ Specialty Grout ❑(;oriel
Non-Water Supply Well: I I Ben ionize Slum L)Other(explain under'g)
shlonuonng ❑Reco%rn
Injection NV ell! X Ror each towthal%etc,ted above.provide amount of mattrials owed:
❑AquilerRecilarge 06rourdwaierRomedatton Neat Cem.:941b ,Wtr:8gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer StucegC and RctidnCIA ❑Salunh Hamer
❑Agmfer]rst ❑SlornwairrDrainage — -- —
❑Exprnntenial Trchnulogy OSubstdeiice C'utatul 7q.Prm itl(•a brief ilmription of the abintlonment procedure:
LIGeolhemial(Closed Loop) OTracer
l lGeotheriial(Heatm ''Coolin Retum) OOthef(cNplaln UnderPoured
' ) —
4.Date well(%)abambned: 6-19-24
sa.Well location: I 3 1 7024
Chemours
Facility Oxim, Facility Will(if iwpitwhk) R•Cenifkaliun: Iftf : ,A.l ar-r^sic ,���
22828 NC HWY 87 Fayetteville, NC 6/24/2024
I'h,sical Addtrss.(n).aid Zip S tonne of Cenifred Well Contractor or W4;110%mr Dane
Cumberland BY stglotng fhiv fiwm, I hereby comfy that the wrll(s)was(wener abantkxied sit
(OdUh. (xconlunce wiNr MA XCAC OX'.0100 sir Y' 6:W ff d1 Cvnstru(nun.Sr,lno4mLx
and thta a copy of(his record has been prnrrded to the well owner.
Sh.I.Atitude and ltrrsitutle in(IeMexrminutru%mvnd%or decimal dogre v
01%ell fall one 4ivicoig t.,,ilrtcwtai 9.Site diagram or additional%dI(kiail%:
You max use the back of this puge to Ilia%ide adddinottal well site details or well
abatdonnteni details. You tray also aliaCh additional pajWS if nectnsan
COS,7 R1( CIO`DF'fAI1.S OF W FAAASi BEING ABANDOM: SUDNIMAI_.INSTRUCTIONS
.mo<"i ar!! na,opte nu.•a tine ry fry,-x.,tar wpplr
NYiIYONLI%itht/wminwiiani1'xowrtAwrtkowirnt.t.xicantlihmittore'7urm loa. For All Welh. Subnut llin Como within ,0 days of completion of wrll
6a.Well[Date
PZ-25R ah;mdonntcm in the following
Dithion of Water Resources.Information Pr ces4ng knit,
1617 Mail Service Center,Raleigh,%('276"-1617
61).Total well depth: 16 oft.)
lob. For Iniecliun Wells: fit addition to siding live form to the address iu lua
abu%e. abo stlmin one cM of this forn i%ithio to days of cumplcoon of%%cll
6c,Borchiole diameter;1 1tnJ abandonment to the following
64L Water level hrlim ground%urfacc: NSA eft') Di%hion of Water Revources,Underground Injection Control Program,
16341 Mail Ser%iee Center,Rakish.NC 27699-16M
6 Ink. For Water Suools & Inkction W'e1M: In addition to sendmt the forth to
6c.0utrrcasinfilenlDhlifknown): (n) the address(rsi abu%c, also vubnn( ooe cup% %A ihrs fomi witlnn 10 days of
completion of%%ell ahardumneni to the -.ouig% loeabh department of the court}
6f.Inner casingibbing length(if l:naw n): (ft.l where atxincinned
6g.Screen length(if know n c 10 (ft.)
Fonu 4W-in Noah Carolim Dcliartinew ofEn%numnicn and Naiuml Rewimes Di%ismn o0li'ater Resoutces RL%ised Atigum xI k