Cleveland_Well Abandonment_20220907

WELL AKANDUNME NT RECUKU For Internal Use ONLY:
1.Well Contractor Information: WEj�L 1 DONMENT DETAIL S
f / Y u✓t G I S ?,' 'com a.For Geoprobe(DPT or Closed-Loop Geothermal Wells having the same
a ..,�
Well Contractor Name(or well owner personally abandoning )oe i>ialioparty well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
24 7 A R wells abandoned:
2Q22
NC Well Contractor Certification Number b S tP O �7 ► Approximate volume of water remaining in well(s):
U
FrV—C�,r C t 5 yV�— L�r►�-(1 :`� �,i FOR WATER SUPPLY WELLS ONLY:
Company Name
f����� 7c.Type of disinfectant used: 1 /
2.Well Construction Permit#:
List all applicable well construction permits i.e.UIC,County,State,Variance,etc.)tfbrown
7d.Amount of disinfectant used: L�
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
DAgricultural OMunicipal/Public ❑Neat Cement Grout OBentonite Chips or Pellets
CGeothermal(Heating/Cooling Supply) Residential Water Supply(single) O Sand Cement Grout —�"Lry Clay
Olndustrial/Commercial OResidential Water Supply(shared) VConcrete Grout ❑Drill Cuttings
Olrri ation O Specialty Grout O Gravel
Non-Water Supply Well: O Bentonite Slurry
_ tury 0 Other(explain under 7g) --
OMonitoring ORccovery
Injection Well: 7L For each material selected above,provide amount of materials used:
OAquifer Recharge OGroundwater Remediation J wards 6�u G'O J
OAquifer Storage and Recovery OSalinity Barrier
OAquifer Test OStormwater Drainage Zo b S C-ti CV`9—+
3T r. I r /C
OExperimerital Technology OSubsidence Control cm 7g.Provide a brief d c.ption of the abandonment�: + k donmeat praeedtrre: `y C
OGeothermai(Closed Loop) OTtacer OGaothermal eating(Cooling Return) OOther lain under 7 aC ` d( OL t g�+` a2j CID i1 CV"' 'e.
0-V\-1-1
4.Date well(s)abandoned: J
5a.Well location: //,, �� /
VYG ratT7fn IN,,eJf ay l.o,
Facility/Owner Name -r Facility ID#(if applicable) S.Certification:
/'11-1 IM �7
/
Physical Address,City, d Zip -Z Signer of Certified Well Contractor or Well Owner Date
� By signing this form,1 hereby certify' that the wells) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Consmtetion Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record h os been provided to the well owner.
(if well field,we tat/tong is sufficient) 9.Site diagram or additional,well details:
N W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constntdton records)ifavailable.Formuitiple injection orison-watersupply wells
ONLY with the same cons,,tru/ctionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: /v r A abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth: (fk) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: hi addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (n•) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
J�
6e.Outer casing length(if known): �" (it) 10c.For Water§npniv&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
N of well abandonment to the county health department of the county where
6f.Inner casing/tabing length(if known): (fL) abandoned.
6g.Screen length(if known): (fL)
Form GW-30 North Carolina Department ofFnvuonmental Quality-Division of Water Resources Revised 2-22-2016

'WELL"AN 0NM T4T KEIA)k ll For l0and Use ONLY:
�r� ��rr r,rr��
I.-Well Contractor Intormation: -WELL DETAILS
_-- C S 7a.For Geoprobe/OPT or Closed-Loop Geothermal Wells having the same
Weft ConUWW N=o(or well owner personally abandoning well on hidher property) Iwen cant uctionldepth,only l OW-30 is needed. Indicate TOTAL NUMBER of
2 L1 1 3 r r. °^ ��`w��11S ab8ltdened:
NC Will Coaaneror C jio_u/NwaW N O ,tell 7b,Approidmate volume of water remaining In wep(s): al,)
( n G t 5 tie-���V �Y_p ` yr7c7.Type
WATER SUInly WELLS ONLII.
CompAaY Aiame 7 3 Z� s•�. of disinfectant used:
Construeftn Permit#:
List agwplicaNe weft c-o-cti-pernws(ix SAC,Cantu Stare trarto—,etc,)ijbnotm L�
7d.Amount of dtslnfedant used:
3.Welt use(cheek well use):
water supply Wen: 7e.Sealing material::used(thick all that appW.,
OAgricultural Oldunicipal/Pubiic Q Neat cement Grout p Bentonite Chips or Pellets
ClGeothemral(itea&Wcowiag Supply) 814sidential Water Supply(single) o Sand Cement Grout &,Ery clay
t]lndustriaVCommercial CIResidential Water Supply(shared) w1coaerete Grout o 7 it Cuttings
Diff,
00CI Spm+ft Grout ©Gravel
Non Water Supply Web:` O Beotonite Slurry O [7 Other(explain under 78)-- — —--
Manitorin _ C]Recoyrry
Injection Wen: 7L.For each material selected ab
ove,provide amount of materials used.
OAquife'Recharge (3Groundwater.Remediation
OAquifer Storage and Rcoovery t7Salinity Barrier
OAquifer'Cea ClstormwaterDrainage �S'�l�l6s ngaElcefi
oExperimentai'T logy clSabsidenceControl gge
CJGeoihamal(Closed Loop) oTracer 7g.Provide a brlefdese rlptlon of the abandonment proeedu�e:
t7Gaotharmal f'oo" Rattan nother aitn under 7 OL I o✓ r ec C t9H G N e TE
4.Date wens)abandoned: U 2 2
Id
3a.Wen location: ` �,,-/ /
0 14 6 r 14` ,-f,M* va
Fac litylOwner Fscairy Wo(ffayplicabie) S.Certitleadou• A
Address,Cif.and Zip Siggaaub of(bRifiod Well Contractor of Well Owner Data
3 CpJ By xI&Wng this fo 9,r.I herby�fy thattin well(s)was(Were)ahwrrawd in
cottdy fted lad,efiew"No."0 accordance-with 15A NCAC 02C,0100 or 2C..0200 wen Co»am lion Sond rds
and that o copy ofisrecord has beer,provided to the well orvrrar.
Sb.Latitude and longitude In degreestminutteseconds or decimal degrees:
(f Vre11 fief•am bdlonz to suffi`iew) 9.Site diagram or additional well details:
N W You may use the back of this pap to provide additional well site details or well
' abandonment details, You may also attach additional pages.if
>R0 7C QN ffMA OF=,U l$MARAM"" MBA ON3
.#ttad3rwe aorabachonrecard(s)(jaaoitable,.F'orntet/tipteejtdioiiorrronw�arsapptywetls
SI1B i.
01V>aYwlthth@ sow odaarruatiat✓alimatanmer y«racr+euMattareform. Ift ft AU Submit ibis form within 30 days of completion:of well
6a.Well m/h� J, abandonment to the following:
/ /� DivWou of Water Resources,InAwmation Processing Unit,6b:Total wen depth: 161714 O Service Center,Raleigh,NC 276WI617
10b For fm_jq(ed Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter:. X� .i . above,also submit oft copy,of this form within 30 days of completion of well
abandonment to the following:
6d.Waterlevel below ground surface: h v w Division of Water KesourcM Underground hoectlon Control Program,
16361►an Service Center,Raleigh,NC 27699-16M
de.Outer casing length(if known): 44 �a it.) 10c.for Water Sunnjy&Iniectegp Wills: In addition to sending the form to the
addrdss(es)above,also submit one oopy oftbis form within 30 days of completion
of well.abandonment to 16.county health department of the county where
6i;>nnercasluglia►ing length(if known): A abandoned.
6g Screen length(if known): N. L)
FomtGW-30 NorthCarolimDepertmenfofBavironmenrnlr)tmliw_r]iWei,u,oftvre..a.�,,...o n_r__�