Cumberland_Well Abandonment_20240731 (10)

WELL ABANDONMENT RECORD For haertwlUwONI'IV
This form can be used for single of mullipk wells
1.Well Conti artnr Information: W'FLI.ABANDONMENT DF 1[U1 S
Tyler Brown 7a.Number of wells being ahanduned: 1
Well Corracfor Name for eclI uwtrr perwually atcird.uun•.,well on his Ire*piopem i P, rontnph iwe.raur ,w roar-waver -vITA *ells ONLY wth Nk• .,,v
r,M+7r![llrel r�arNlrUlnlrNlf,Iron t r,rr,4r•rrrll,Vrr'(ran
4625A
NC Well CnrdmdnrfcHlftrtlinn Nnnnccr
7h.Approximate%olume of w our remaining in well(s)WA (OIL)
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
compmt>Wine 7c Tope or(dWnfectant toed•
2.Will C"Onwtion Permit M ,
by alf,rpphcuAle*ell;wrmils n.e.t urinri.Soak.I amerce.I",t,nn,etc.!*!,Enure 7d.Amonnf of difiakctant INE/:
J.Well use(check well use):
Water Supple Well: 7e.Sealing materials used(ch"-all that apple):
❑AFn:ultural ❑hltmtctpal PuhltC ® Nctl Ccmcnt Gmnt f7 Hentonitc Chips or Pellets
❑(kodicrtred(1canng-Vooling Supply I ❑Rcsiduriial Water Str)ph isingic) ❑ Sand C•enierrt Grout ❑ Dn C U%
❑Irdusinal:Comnicroal ❑Rcsidennal Water Supple islwrcd) ❑Concrete Grout ❑ Drill Clnttngs
❑Irn'•tion ❑ Speaalty Grout ❑Graxel
Non-Water supply%ell: C] Bentonite Slum 11 Other(explain under 7g)
PDhlunttonn ❑Rcemen
In jcetion��ell: 'f For each mac riot scicrad ahnxc,proxide arratrunt of material.•veil:
❑AquderRecharge ❑GroundwaierRenaediaitoo Neat Cem. :941b ,Wtr:8gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Redact\ ❑Salumn flamer
❑Agmlcr lest ❑Slontnx:letDrainage —
OExpenmenial Iecbnolog.% ❑SubsidemeC•uratul
7L.Provide a brief description of file abanrhimnent procedure:
OCrenthertual(Closed Loopi UTracer
Poured
OGeathemtal(Heating/Cooling(Heating/Cooling RklumI I IOthct(cx lam uncle*'g.1 - -
4.Date*00)abandoned: 6-19-24 �.
Sae Well location: T24
Chemoura 5.CertificaHan: Ifr::,:.:w•.'.•� '' -' �F;iC)I,i+t3+,rcr N;urc Fxiloin IThr(ifapplicabkl
22828 NC HWY 87 Fayetteville, NC 6/24/2024
Plu steal Address.(a).aid Zip 5, W,ItC of(Cnif><d W etl(•narrdetor,n WCII O%cr Dune
Cumberland By siXiiaig thiv Janet, 1 hertehy cerhA that the well(s) was fwere,ahan,kmed tit
Coma, Pn..EWcrtnft wilNo(PINI arronlance*file IJAVAC0.C,0100or1C1070ff-rNCev7s'hut'hun.\ferrkkur/r
and thtd a tnpy of this record has hetvt pent•,W to the well owner.
51L Latitude and longptwrk in dcjpw%iminutrv.wcnndc ur decimal drLtxrv:
oI,sclt fekl otic L•tulnag i,adtic.c,at 9.Site diagram or additional well tlMaily:
You nosy use the back of this page to prov ide additional hell site details or cell
N W' abandonment details. You ins+ also attach additional pages if mcessan
CONSTRI'A TION DETAILS OF W ELIaSI BEING ABANDONED SUBMITTAL INSTRUCTIONS
.nGAlt wril.n2+Ira.It'll/rra,r& , 11 a,whe'll, 1—ntniapic aye'ti 1 rr rr,n-water supple
wrll,+ONLI'with else eorme c,ua trwtam,ah„rnArren.•„r-i•xr can sr✓•Ied.vre.F•mrr l0a. For All Wclli• Subtrut ifin femi otrhm :0 days of Completion of xxell
6a,Well IDai:
PZ-38 ahandonnicnt to the follnuing
Dh Won of Water Rowonrvc,•Information Processing Unit.
trb. rotal well depth: 9 10.1 1617 Mail Serxiee Center,Raleigh.N 176"-1617
lob.For Inixydon Wells: In addition to widmg tlk form tei ilk address in lua
r.r.Fkrrt•Iwdr diameter:1 lin.l aboxc. also subunt one copy of this fomt xvnhui yn days of completiun of%%ell
ahmdonnenl to the following
Divislon of Water Resources,I odcr•gnound Injection Control Progriw,
fill.W titer lest 1 below Lrnand wrfarr: NSA (ft.) 1630 Mail Scrxiee(•enter•Rrlci,h.NC 27699-1636
lfk-. For Water Suooli & Inkrtion Wells: In addiooii to sc dmg the fomt to
tie.Outer casing;length Of keiow n): 5 (ft 1 the address(esi abo+e. also submit one copy of Ihis form within n
t days of
completion of+sell abandonttetn to the cotwv health department of the :0uH1N
sxlicrc ahaidnied
I&Inncrcasin 'tnhinL kny.-th(if known): (ftl
tag•Scorn Icn0h(if known):4 (ft.)
Fomi GW-30 North l oat•tires Depanu en of En.tmnnk,v nil Natural Resotuces Dis esmn of Vrater Resources Re,iced August 2t1 t