Cumberland_Well Abandonment_20240731 (13)

WELL ABANDONMENT RECORD IminKmil(;scUNJ.ti•
This form can be used for single or mdtipie wells
1.Well!Contractor Information; W'El.I..ABAVbIINMENT DETAII ti
Tyler Brown ?a.Number of wdls being abauduncd: 1
Well C'omracnm Name uu s,cll os,ire per+aredly Arirkfoiung actl on his)k:r propertt: r w mkluph' m oetl1wr ,w ,&,n-oalrer rkjyA rrlts ONLY wrdr NK swat
.,.n.rrka rl�N„i14i,kh NlnlYllf.I.N „r.N�x,!l,NM1 h�r1,1
4625A
NC Wdl Cainritior Ccnlfiadinu Nnntcer 7h.Approximatr i r fume of w Attr remaining in wdR(sA (fah)
SAEDACCO FOR W'ATF.RSIIPPI.Y WELIUSONLY:
(.,n,r:,m Na•tk 7c 'f�pe of disinfectant used:
2.Null Construction Permit C,
I nr,d7 iq+pfu wilt wwN pwrnM.%u.w-t'wrip.5raxr.I down%e• Lrrr,hour,w1r. it Am,ra, 7d.,amount of disi"I'MAn(uxd:
J.Wdl use(check well usrl:
Water Supply Well: 7e.Sealing material%o d(check all that apple):
❑Agttculturrl ❑INimocipalrPtibltc 0 Nc3t Cement Gran I l Rernonnc Chops of Pellets
O(ieothcritd lNcanti 'Cooling Supph l ❑Re%idntnal Watcr tiupph I%mFlc1 ❑Sand Cement(imut ❑ Dn(la%
❑Lrduststal Comnicrcutl ❑Rcsrdersoal Watcr Supph(shared ❑Corwrele Grout ❑[hill Cuffing¢
01trig1:1 ❑ Specialh Growl ❑Gra%d
Nan-W Ater"upl,l+ NN H ❑Beraonite Slum U Other(explain under 7g)
➢G klotaloring ❑k%i UN CI%
Injection W'cil: X For each material u•Iccted ahose.proOde annual of material.a%cif:
DAgniterRccharge ❑Cinoundu;nerReniedimion Neat Cem. :941b ,Wtr:8gal. Sand Cem. :lb ,Wtr:gal.
❑Aquifer Storage and Reco%en ❑Salunn Ramer
❑Aquifer Iisl ❑Slommatcr Drainage —
❑Espenmemal Iechnolop ❑SubsndenceC'oraml
?g.Provifle a brief dcscrilniun of the Abandmmcnt procedure:
OGeothem>:il(Closed Impi UTracer
Bentonite chips used to fill the screen and poured grout
OGeothemnt(Neann +Conlin Return) [IOther(c% lam urd%Y' ) t _
down the well 6 "�;���"% V ��
4.Date w0m abandoned: 6-19-24 II'1 3 2024
3a.W'eR location: L
Chemours
Fxila.IAw(ifapplicabki
S.Crnilkadan: Ulf'
22828 NC F147Y 87 Fayetteville, NC
6/24/2024
Ph,skal Address.Cm.aid Zip [i Wine of Cleo 1111k t Well 01111ricror in Well(1,rser Date
Cumberland _ M .signing this form, t hereby cergfy that the well(si was/weret ah vidoned tit
n Paic�9ldcmdraikni N., (111% a!conlance with 114.NTAC 02C.0100 ur 21" 0XV Well Construction SttmtdMA
and that a tryiy of this record hm been prm-ided to the well corner.
Sh.Latitude and lingitudt•in degrresiminute%:%tcnnds nr decimal det;rec,i:
Ill well fitkl.oia 4'u long h%iiRukitl 9.Site diagram or additional%ell detach:
You mat the tlk back of this page to pm%ide additional well site details or%ell
N « abatdonnicoa details. N'ou nta% also a((ach AWrnorul pages if necessan
CONSTRI(TION DETAILS OF W ELI.(SI BEING ABANDONED SUBMITTAL INSTRUCTIONS
.86nA.ri:aura+lry,lr+,r,ma,�nh�,U a,wh�''k h ffnifaprc rA'e,11 ,r 1v ra,mk.!!ar wprlr _
%efk ONLI'k,rh the.avow t,ur.rrxa n„n A yr Amw wni.i.,x caw akhm,l,orw.N,nn. too. For All W dli: Subnut ifin form ulthin ;0 da%s of completion of%tell
r.a.%%ell 11I=:
pZ-32 abandonment to the following
Division of W'Ater Resource%.Information Processing Unit.
6h.Total sell depth: 18 (ft,) 1617 Mail 5er%ice('enter,Raleigh.N('2 769)-1 6 1?
lob. For laitylion Wells: In addition io xiduig tlic form to Ilk address nt Ilia
6c.Fkinlw)Ie diameter:2 fin.) abo%e. also subritil%,tie copy of llus form wnhm :n duns of completion of hell
abatdonnlenr to the lollm%uw
Di%Won of Water Remrcea,Underground Injection Confnil Program.
(,if.W Atcr ks%i below grnaiwl.wrfAcc: 12 (ft.) 1636 Mail Service Center.Raleigh.N('27699-1636
13 Inc. For Water Sunnh & Injection Wells: In addition to sending the fonu to
6e.Outer casing length(it kneian): (ft.) the address(esi abote. also submit otte copN of this fool aithm to da%s of
completion of i%cll abandanmer to the couraN health depattnieia of the cousin
a herc abandoned
6f.Inner casinghahiag�pf lauswn): (f1.1
6g.Screen length(if knm%n1:5 1d.1
Fors GW-34i Nonh C'andtns Ikpannrcin of Eu+ironnkn aid 4ai,aal Resources Isis%skin of Wancr Rasourccs Re%tscd August N)1 t