Cumberland_Well Abandonment_20240731 (12)

WELL ABANDONMENT RECORD F"tInunul Use ONIY
This form can be used for single or multiple wells
1.Well Unntracmr InfornAtion: WFLL ABANDONMENT DETAILS
Tyler Brown 74.Number of Moll.bcitir abandoned: 1
w'.II Cmdl kw Name iof well ow ner personally ahandnning well on his lrr praperts 1 F'Ir mndoph olle,I.,.( 'v ww- ,mer strpp/v weds ONLY reel, i1w ,.Am,
..N1�rrtf(IN.W.]l'11rk11NIM11 ir( !.rI�DUI♦NlV'I!r'MI.'h�rl11
4625A
NC Wbll Cnnlmctnr(-cttnfiarli+n Nnntter
7b.Approximate iolurne of Nato rrinaining in wdl(sy (>;al.l
SAEDACCO MR WATER SUPPLY WIELIiSONLY:
Cotrpany Name .c.'I pe of disinfectant used:
2.Well Coastraction Permit N r
1.1st 4114 litublr tied prrwils n.e.VI rur.Shoe.1 anwne byetririm ert."I bwwN -d.kinotint of d6driftctAnt u.d:
J.Well use(check N(Al use):
Water Supph Well; 7e.Staling materials used(check all that apply):
❑AFncultural ❑INimicipal;Public ® Ncai Ccmcm GrrNn ❑Betaomtc('hgx or Pellets
❑(icothermd(HcangeK'ooling Supph l ❑Residervial Water Supph imriplo ❑ Sand Ceinera Grout ❑Dn(la}
❑Irdnstnal:('omnicrcial ❑Rcsidctvud Water Supphisburod) ❑(oncrele Grout ❑DrillO"lings
[31frigjIlull ❑ Spayalt%Grout ❑Gravd
Non-Water Supply Well: U Beaontte Slum U Other(explain under 7g)
INklanionug ❑Recoirty
hijection Welk N For each material wdected above,provide amount of mlurrial,its &
❑AgndrrRccharge 06roundwaterRenredmitori Neat Cem.:941b ,Wtr:8gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Recosen ❑Saltntn Hamer
❑Agnder lest ❑SlomtwatetDrainage —
❑Expenmcnial lechnolog, ❑Subsidence Control 7g,Provide A brut dt-wriptirm of the abambuuttent proceilurc:
I-1Gcothemial 1Closcd Loopt UTracer
I1(xottkm4dlHcaun +Coolin Return) UOther(explain under7 ) Bentonite chips used to fill the screen and poured grout
down the well • f
,r ., `
4.Dare Ndpsl abandoned: 6-19-24
SA,Nell location:
Chemours 1
Fxtitty'Qw ncr Namc Facild%ION 01'applicalik R•CCrtllkatidtn: l3'f�•..s :�.�
22828 NC HWY 87 Fayetteville, NC 6/24/2024
Ph+steal.Address.(iiy,aid Lip ;war Ceed'rtd Well Collimitir of%'ell(Muter flaw
Cumberland 4,myning tbes firm, I hereby cerob,that the well(s) was tw ere i ttlwrdoned or
Couwy P.u.d I'L11I -11F.ni N" (14%1 arzvnksi'e widt MA NC IC 02C.0100 or 2C O:M Well(irrihuc'(rnn.V(mditnls
and that a aripj of this record here heat prrn ided to the welt owner.
Sb.[,vftdc and lon►IkUW in dtyprrslminutrs;sccnnds or decimal dtgrrrc
Ofweo meld,ow latlarrg n wiriciew) 9.Site diagram or additional well details:
You mat Inc the bacl,of this page to pro",ide additional well site details or Nell
abandut nicru details. ti'ou mas also.ilach additional pages if iieccssan
f ON',1 Rl( 110'% DE:IAILS OF N4 E.LLINI BEING ABANDONED SUBMITTAL.INSTRUCTIONS
-i.nir H,ji Irnc,!ra,A+N rr„.1.1-{!alwh 14' l.!r naUG/'ic ug«nrlrr'v rr•n-Ildler w rlr -
"Vil'ONLI Nnll elk'41mr"mmi m"t Via. For All Wells' Subtnu this form Nlthrn ,0 dass of completion of well
6a.Well IDd.PZ-29 ahardonntent In the fdylkiw'ing
Division of Water Resource.,Information Pr(jce%%tng Unit.
6b.Total Nell depth: 18 (fl,) 1617 Mail Service Center,RAkigh,N('2 76941-16 1 7
10b.For Injection Wells: In addittou to sending the funs to Ilk addiess in lua
6c.Borehole diamMer:1 (in.) above.also submit one copy of this funs iiuhm in dam s ol-:omplciton of well
abandonnteru to the follouuit•
Division of Water Reraurces,Undkrvouad Injection Control Pragrant,
red.W atrr level hdaN y!tvand wrface: 12 (ft•1 163o Mail Scnice('enter,Rakish,N('27699-1636
13 Ink.For Water Sumily& Iniecdow Wells: To addition to sending the form to
(.c.0utercaainAlength IHlsownl: (hl the :rddress(esl :iboce. also submit one cop% of this fomr within in dais of
completion of well abandonmieni to the cotuuv lbmhh depannrent of the cairn
6f.Inner casiny+tnbing 11,en>,Rh Of know w here atmridnncdnl: (ff.1
6=.Screen Ir tgth(if ImoNnt:5
Fami GW-3u Nonh('arohm Depanniety.if Fn.Iruunttiil:nd Natural RewuKes-Dis tsion of Water Rcsoarccs Res ned August 4'1