Cleveland_Well Abandonment_

WELL ABANDONMENT RECORD For Internal Use ONLY:
L 1111clor 1 n: w1L ADAND01MU T DETABS
t +7'�' 7a.For CeoproboMPT or Close&L ep,Geothermal Weds having the same
Wed Contreetor Name(or well ownerpaneo dly sbmdmins well on hislhor p¢opmty) well constructiouldepth,only 1 GW 30 is needed. indicate TOTAL NUMBER of
-d..1(o awells ebmdoaed.
NC Well Canmr�or Certification Number 7�Approximate Volume of water emining in wen(s): (gal.)
��. ti,' ,r�C R C FOR WAT&R SUPPLY WELLS ONLY: '
Name 7e.Type of dhinfeehant used• k-A
L Well Construedon Peewit It.
Lid all gwfcabk neD msabucdon permits Rc Wr,Comity,&Xk Pariaacy dtM)Ubrown 7d.Amount of dlsinfectaut used: t 0
3.well use(ebeckwell use):
water Supply Well: 7e.sealing materials used(cheek All brat apply):
OAgricultural OMimicipallPablic O Neat Cement= -• to grips or Penes
OckotTre�at(Ifeadowcooling supply) 'artist water soul'(�) 13 a R -6 !` 4'�y
Oh>dustiiaueommeetc»al , OU*Jm al Wow supply(altared) ®Cam ft G" N 0 V 2 2 2022 0 Drill Cuttings
01ni lion specialty Grout
Non-water S%v*Wdl: O Bmtonite S tamer(eVlm user fig)
phlg ORecoverr l V"b�` OG
WO, 7L For each material
above,provide amount of Materials used:
GAquiforgedbarge 00r�cnndwsterxemedis ion
OAqu&r storage and Recovery Osalingy sassier
DA"Ted OStormwetw Drainage
O&M"Technology OSubaidence Control 7gr Provide a brief dewrlpnon of the abauddameat procedures
OGeothrrmal(Closed Loop) O'er
OG Return OOther lain under 7 w ei v�)¢-S s(
fir. Cc e_ %v e, e
4.Date well(s)abandoned:
Sa.Well locafion: r
Fam it Owner Name �— Faciflly IDO(ifyiplicabb) L
Fhy ial Address,City,and zip - tiigaeatno w err wen Owner
By sipft this forts,I herby cattf}'that the w 4(s)was(,Akre)abandoned in
y Faccel ldamifiadoo No."4) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Cans"wUm Shosdarde
and(hat a copy of this record has beets provided to the woU owner.
5b.Latitude and longitude in degreashol atedseeosds or dedual degrees:
(ifwefi ECK one kviong is sufficient) / 1� 9.Sits dlagrum or adiflonal well detalb:
1r 19 You may use the bade of this page to provide additional well site details or wen
N Z� 1 W abandonment details. Yam may also attach additional pages if neaesary.
CONSTRIICTION'DET U OF
.ltmchweUcow&HcdN,e=d(s)dayuwzL Aormuldplebdadonor—woura plywas
OlvLrr,tai Min setae ea�uamcdan/abardamrok yea amr arrbsttf ae+aJ 10a.For An walk: submit this fors within 30 days of compleelm of well
6a.well ID6: abandonment to the Wowing:
Division of Water Resources,Informtlon Prooening Uolk
6b.Total well deptic 1617 Mail service Center,Ra43gL6 NC 2709-1617
10b.For Inlecdon Wells: In addition to sending the form to the address is 10s.
6e.Borehole diameter: (ia.) above,also submit one copy of 96 foam within 30 days of completion of well
sbandenmeat to the fonowing:
- _E r,;
6d.Water level blow ground surface: (R,) Division of Water Resourc a j,90"Injection Control Program,
1636 Man Service Center,RWWO,2 C 27699-1636
i
6L Outer easing length(if►mown): 00 10e.For Water Saooly&Injection Wens: In addition to sending the form to the
addr"Kes)601%also submit one copy of this foam within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner easingitabing length Of(mown): abarktonad
6g.Screen leuO(If lmown): (M
Form OW-30 North Carolies Deportment of ftmumeotel Qo.lity-Division of Water Re mureas Revised 2-22-2016