Cleveland_Well Abandonment_20220628

WELL ABANDONMENT RECORD For internal Use ONLY:
`1.Well Contractor Information: WELL ABANDONMENT DETAILS
f �Y1�� ]C',���e9' 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name r well Owner personally abandoning well an his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
22LQ'ir A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water retaining In well(s): d (gaL)
S erph FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
1��-Z�� 7c Type of disinfectant used: 112l(_ _
Lut all applicable u`eM constr ction parmas(Le.UIC,County,Stare,r'artmnar,eta)0-un �3 D
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Wen: 7e.Sealing materials used(check all that apply):
❑Agrictdtuml ❑MunicipaUPablic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothennal(Heating/Cooling Supply) Residential Water Supply(single) Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
[Hrrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
injection well: 7f.For each material selected above,provide amount of materials used:
OAquiferRecharge ❑GrotmdwaterRemediationAYflls
❑Aquifer Storage and Recovery ❑Salinity Barrier {-
❑Aquifer Test ❑Stormwater Drainage _
❑Experimental Technology ❑Subsidence Control 7 provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer / ) � j� ' 1
❑Geothermal(Hea' Coolin Return) ❑Other(explain under 7g) Rrr W��
` �?��r� �yr.Gn�• ti�.l1 �-ol,�''ir 1n�-el l
4.Date well(s) _(s)abandoned: C7 2 It
5a.Wen location. 2i b� g
F 511 T_
Facility/Own Name Facility ID#(ifappliceble) 8.Certification:
Physical Address,City,and\\Zip I Sigmture of Cc faced Well Contractor or Well Owner Date
CJQ_V Li 0'Y' � By signing this form,I herein,certif-v that lire well(s)nos(were)abandoned in
County Parcel Idemifintioa No.(PIN) accordance with 15.4 NCAC 02C.0100 or 2C.0100 Well Construction Standards
and that a copy ofthis record has been provided io the well oitwer.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laMng is sufficient) 9.Site diagram or additional well details:
N ©�� �5l 1 W You may use the back of this page to provide additional well site details or well
7 abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WEUM BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach xrllconstructionrecard(s)ijmvilable.For multiple injection ornon-timrersupplyar!!s
ONLYwuh the same cotuirrertonlabmdonmenLyrou can submit onejorm 10a.For All Wells: Submit this form within 30 days of completion of%veil
6a.Well ID#: abandonment to the following:
+r t Division of Water Resources,Information Processing Unit,
6b.Total well depth: `� (ft) 1617 Mail Service Center,Ralel h,NC 276994617
I) 10b.For Iniecdon Wells: In addition to sending the fort 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 ' (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 276994636
6e.Outer casing length(if known): I V (g) 10c.For Water Sunnly&Injection Wells: In addition to sending the form to the
addres(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
�
ry•( (t`-
6E Inner casingltubing length(if[mown): abandoned
.�1 -ift) 6 1f!4
6g.Screen length(if known): MA (fL) J U N 2 8 2022
`R' ^� --12016
Form GW 30 North Carolina Department ofEmironmentel Quality-Division of WaterResourees MW, -y,1 Sir'� Re yise42 7
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