Cleveland_Well Abandonment_20240311 (2)

WELL ABANDONMENT EtECQRD For lritamal Use ONLY:
This faint can be used for single of tnttiliiple titfls
1.Welt Contractor Information: WELL ARANDONINENT DErAtf R
Stefan Smith uell.onti 7a.Nwnber6l'"dls being abandon)is i
�WellCoutractorName(onl ltn�se�p�sntullyat>asetautn; 1krpiopcny) Fw' nlullipte. vVeettar Ormi-wYIrerI 810*1 walls ONLY wuh the swue
cmasrrrrcrlai imGardnirrra��+r,rnn ccor.r+fxi+Jf w1,<�rrtl.
3576-A
74C1Vd1.CanimgorCanifGailoiiNntitbor 7h.AppnixinkAtc;volume of water ritittMing inwell(s);
SAEDACCO FOR WATF.ti SUPP1.YWELLS ON9.Y;
Company Name
7e,Type of dhJulectaut iscd;
2.Well Cousttuedon Permit 0:.
I1Si RR a+ptlkcUbld NelilkraRlLY tf ai t'tRlf!J:Slarti.3'nriarrr,L�'nc4ior+„elc►jGmwn 7d.Atnouit of rl 1 of iant usedd:
3.Weil Usti(cdcckWell u,%-):
Water Supply Well: 7c.Scaling matcrialsnscd(check all that apply): .
1]Agtitulhtrat ❑Municipal/Public• M Neat Cement Gioui CI 19cntonite Chips ofNlcts
OGrntiicnn:tl(Hc:ttiu)Coolitio Supply) 1712csidential Witter Supply(single) ❑ men Sand Cement Gmut �, ❑Dry Qkv .
❑hulnslrimll(ottintctclal Ol(csideutial Water Supply(stuired) ❑ConcceieGrou¢ 13 Drill CStldngs
l7lrti alai '0 Specialty Grout ❑Gravel
Rau-Watcr Supply Well:- C1 B6totdteSlurry i C)Other(explain under 7g)
19Moriitoring DRccovety.
Injection Wctt: 7f,For each tuateriid se1-ected above,pros ide antount of fitater(als used:
DAgntfer[tecitarge, OGrouiuinnlerltentetiinlion Neat Cem.•471b ,Wtr•4gal.1 Sand Cem.•lb ,Wtr•gal.
I7Arluifer Slornge and Recovety USalinity Darricr
I7Aguifer Test 0] lontn%ater Drahwge
Bentonite.:ilb ,Wtr:gal. j
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OEyta tintetual Technology I7Subsiaten>tc Conatnl 7g Pru%idc a bri<f dixcriptian of tit abandonment pn►citluru
®Geolhennal(Closed Loop) ©Tracer
Mixed drum of grout (3751b Portland cement 51b bentonite
Moothemtat(Hc atiLj ootina Return) 13011tci'(�\ lain under 7R) .
powder and 28 gal water) then tremie grouted wells.
d.Date we l(s)abandoned:2-26-2024
Sa.�YclllucaFion: I� L r
White Tire Center Z624
PaC GenlRrntiaJ
ilit)�lthvticr NameFxility Il7m Cfappiicabic) In,�:r�r � ��-,•.,e
2715 Fallston Rd. Lawndale, NC 28090 Yr VIL '. CVA'1+•_ " `� 9/2024
Physical Address.City,and Zip' tsk-Wi-,an•: Certified Wolf Cantn.mr or tVclI(hair Mac
r
Cleveland Dj+sigjfiq 11ais farna;I bemby certih-d' rl the u'e11(v)teas orere}ahrmdoned in
conuty Parcel lidcidJki itNo.(PIN) accordynce with l3AAVi1C•02C,0100.rrr2C.0300I'Mul1 CoijViarcHun Strmrkrrds
arm titan a mpa oftlris recorellrresbe'eir prordrferf la the well owner;
5th 1 ltintde and IongitUdo in asegia;estnttnirtes/seconds ar decim,'tl degrees:
(Ifd•all 1'n.id,ow Moms is nim*li). 7.Site diagrantor-addifioual well detalls:
35.474260 81'.510389 You tuay use,tlie back of diis.pctge to provide.additional well site detaib,or wall
N . W abattdoituma de'14S.'You luny U[S0,11MIt atlditionral pages if necessary.
CON'TRli(-nw4.DVTAIL.0 OF NVELLISI REINC.ABANDONED SURIIH'ITAt,tNSTRITC nONS
:Maraca,it-'ell roawrafeliorl rVEmllsl if nWabli. /'err nminple bVecdon'nP robe-miler sApplp
it-elk ON1.V im/i dw smw raaismxrlrnr uLarrluxi:arrat,)uR rnn urbmlt err junrr IQa,.For All Wells• Suhtnit dais fcrtsit,Within 30 days of eamplction of well
6a.1Vdl ID#:Mt^'-4 abandonmcatta thcfallo�f�n;c
Dlyisitin of NatcrRctntic�,Infonnation Processing Unit,
Gb.Tatal well depth:
20 1617 Mail,Scnice Center,Milei;th,NC 276994617
((B.) i
lob.1,760n leclialn.Walls: In addition to sanding die fotnt_io the adtltess in iQa
Gc,Borehole diatneter:2 (in.} above.also subudl one copy of dtis own ttithiii 30 days of completion of tttill
gabittidoutuct4 to the r6flowiag:
ll
Gd,Water bclo�'" 12 Division of Witter Resoutics,Underground firjectlun.Cotilrgl Program,
gtrtltid surFlcc: (ft.) 1636 lltail Scnicc Ccreter,Ralcigh,NC 27fi9')-1G3G
Gc.Outer casing length(if hvtawn); (ft•) loc.rnr\Parer Sunnty'A Inicetin i wells: M addition to sanding the fort to
the addresses) .above, also submit one copy of this-fount wilbin 36 days of
completion of well abm doiim:m ro ilia;count),health depkintent of ilia county
Gf.Inner casing/tubing fang-th(if known): ({t) where atnndancd,
Gg.Screen length(if knott'n); 00
I
Pons M140 NanhCaroUro Depwinem ofEmlmument aril Mimi Resaames-Dh,kionoMhEcrReso I s Revised Aqua 20B
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