Cumberland_Well Abandonment_20240731 (15)

WELL ABANDONMENT RECORD Forlalerntl Use ONL1'
This form can be used for single or mtYtiple hells I j
1.Wer Cann'actnr Information: WELL ABANDONMENT DETAILS
Tyler Brown 7A.Number of smells being abandoned: 1
Wdl Commim Nang im well ow wry pmawdiy alv teknung well on hiss.Ikt proper)i r r melmfJt 014.0 m ,w trMt-tier supfd, .0k ONLY rrrh Ne• swot
.,rn.n„t,•ri,fig„«k u,m,nr ,.��„a„Hh,r,r�+„r M1inn
4625A
N('\1111Cn+ar,i ,arc ih,+n Nonbct
7h..Appm\imatc solmrtt of wetly'nntamin( m wc111s1: igrl.l
SAEDACCO FOR W ATFR SUPPI\ W FI.I.S(M 1 1:
r. m ",III
'c. I N Ix-of dnntfcrtant used:
2.Neil Construction Pertait M:,
L.a dl„rgdaubk well prrmiLi,m.e.(r ftn..W Me.I ariame Inter Irom et-if Amin
'd. 1m(xint ref JisinArt.rnt ux(1;
J.%%ell ace(chrCk'well use):
Water Supltl.Well: 7e.Scalia%materials used(check all that appl�):
❑Agrknlrural ❑tNmtictpall1liblic a Ncat Ccmcnl Grout f7 Berdonlic Chips Of POICIS
❑(icothcmud(HcatnngK'ooling.14Mph I ❑Rcmdc111a1 Water Supple Isingle) ❑ Sand Cement Grout ❑ Dn Cla%
❑IndusinaUCommcrciat 011cmdenual Witter Supph ishared) ❑ Concrete Grout ❑ Drill Cmlinps
❑Irrigation ❑ Spevdtr Grim ❑Gra\el
Non-Water%uppll%Hell: I I Berm tte Slum l i Other(explain under 7g)
Illstonuonng ❑R&o\cn
Injection Well: 7f.For each material selected ahmc,preside amount of materials aced:
❑AquderRecharge ❑GroundxtialerRenteJiation Neat Cem.:941b ,Wtr:8gal. _ Sand Cem.:lb ,wtr:gal.
❑Aqutler Storage and Reco\en ❑Salmrn Learner
OAquder Icst ❑SlonmsalcrDrauwge —
❑Etpenniental I ethnology ❑Subsidence Control it,Phis ide a brief descriptirm of the abaedtunnent proctvlurr:
OGeothert:d Wliiscd I.00pI OTracer
Bentonite chips used to fill the screen and poured grout
OGeothcmi.'rIIHWnni;Cnnlur.,kilun,l f70ttnerlcc lam�lder7 I
down the well
4.Date•wr111s)Ahandnncd: 6-19-24
5A.Well krcation:
Chemours
Faeilth Ontiet Name F.uilns InMr,fapplicahk?
8.fenlfkation:
-� `'G acw 4 22828 NC IiWY 87 Fayetteville, NC �yts
6 0 4
i'ln sicat ktldress.(ib,did Zip Sr fMrR of('¢mind)'ell CO111 aelar ut W'dl(hoar Dag
Cumberland By mgmtrk du%a:rim, 1 hereby cergA-that the wells)wds(weret ubmukrned ter
n a.t1IJ ttl,n:�atimiNo(PIW1 dr't„rthi ee¢tea 13.E.>•CACn:c,0100or:C O.NV Well Constrt(ction.X'nmm snix
and ratw d cop)of this reranl has been provided to the well owner.
5b.I.aritude and krn%itutlt•in ck-MrslminutrVwCoinds or deeumal dry;rerN:
(if well field arc IaLAbxg it sarffkkral 9.Site diagram or additional well details:
You nuo ire the ball,of this page to pr(n ide additional wren site details or well
\� abadennkra details. You mac abo mach a Witional pages if mcrssan
CONSTRT(TION DETAILS OF W ELIASI BEING ABANDONED SC'B?*IITTAI.INSTRUCTIONS
.!lath.ci7 ronetru.ft:nr naurd, :!a,,ul,b),. ".,r nanrtfrir rn,.ana,;„r rt:di..urn <u1yi,
"vith O.NLi'a rrA the timer uta+trm mutt akunk„mmrrie iow tan tuhmu are 7v rm Ina. For .All Wells• Submu Ihts form nithin 30 da)s of completion of well
6s.Well IDS:
PZ-43 ibmidennicni In the folla)rng
Disisi(m of Water Remiarce..Information Prucesmag I nit.
1.h, I-it it well depth: 9 (p1,) 161?Mail Smiee Center,Raleigh.SC 2 7699-16 1 7
Wit.For Inicction Wells: in addition to,ending the form to Ilk address tit Wit
abo%c.also submit otic copy of Ilus form wuhin 30 dim of completion of welt
tic.RtinMdr dlameler:1 (in.) abaMonntern to the follonIng
Disisina of Water Rnources,Undergnwnd Injection Coatrul Programs.
6d.Waterlcvel lichm Lmosnit surfarc: 7 (h•1 1636 Mail Seniee Center,Italci%b,N('27699-16M
4 10c.For Water Sun nh & Iniecthm Wells: In addition to sending the fo
rm to
(.c.0utercasinglcn hliCl.nownl: (h•1 the addresste,i abose. also subnut one copy of this foal nithin \n da\s of
completion of ncll abandmuncru to the count, hrahh dcpannxre of the cattntt
n lierc ah.i ran rcd
6f.Inner casin;!-'tubinL length(if known 1: (ft.)
6_.Screen knj1h(if knownl:5 (ft.)
IF„n I AI,-�,I Nonh Camhm Dcpunmcn of Ern imnnk d and Naeral Resomes-Dt%lion of Water Resources Res Lscd August?01(