Cleveland_Well Abandonment_20221028

5
WELL ABANDONMENT RECORD Forlm¢hilt;q ONLY:
Tltis forme-an be used for single or muhipl,,sells
1.%%'ell Contractor Information: WELL ABANDONMENT DETAILS
Stefan Smith 7a.Number of n clh being al►anduned: 1
Well Cornacior Nante for%tell mttii petsorsill)abanhithi UcII oil his"llet pinpery) F01- rllrfO(Y1C iNfICUMI ,Ar rYrt/-tlarer• sigysl%- we li ONLY welly flw b ie
1 ",w if,chle ir'-d"21"'1 ml.'rrrlr,)wi van solt'nN Ivie forl't.
3576A
NC%V01 ContalclorConlf:caliun NowbcT 71).Approshnate volume of sruter remaining
SAEDACCO Inc FOR WATER SUPPLI'NEi.LS ON'i.Y:
C°rlvaln Nalnc 7a'Type of disinfectant used:
2.Well Construction Permit
L-w4X gjpkr•uGlr rrs'l/lunrrily o.e.('wird(r.Stale.1 iirm,rce.byerliou.eir.)yNitritrri
7d.Amount of duinfeLKanf used:
3.Wdl u.w(clued.n ell use):
Water Supple Well: 7c.Scaling materials used(chcelc all that apply-):
❑A,gri.nhural ❑hilmicipalt'l'oblic 17 Nett Ccmcnt Grout 13 Hemooitc Chips or Pellets
❑Gcotticmltl(Hcniine('ooling 1yupply) ❑Rcsidential Water Supply•Isinzlc) ❑ Sand Cement Grunt ❑ Div My
❑htdustri:dKbmntcicial ❑Residential Water.Supply-(shared) ❑Concrete Grout ❑Drill Cuttings
1311ti2tion ❑Specially Grout ❑Grovel
Non-Water Supply Well: U$ct)lonite Slug' IJ Outer(eq)lain wader 7g)
®lvluuilorint ❑itecacely
Injection Ncll: if.For cash material selcetcil Above Iwovide arumant of materials used:
❑Aquifer Recharge ❑Gioundnmter Renwdiation
El Aquifer Storage aix!Recovery ❑Salinih•Barrier
ElAquiferTest ❑SlornmalcrDrainave Bentonite.:51b ,Wtr:gal.
❑Cxperitrtentnl 1'txhnnlogy ❑Subsidetxe C'wutvl 7g Provide a brief dLicription of the abandonment procedure:
1_I1Seolhermal(Closet!Loop) OTracer
Pour hydrated bentonite Pellets
C:IGeedtunwl(HQititnf'CoolinR Return) C70(11cr{cxplain u►xicr 7R)
1.Date well(.):aban4loned: 10-10-22 _'4�
ia.Well location: no T 9, s 7n27
PPG
palit S.Certification-,onCertification-,r �) In�Or.ra;?�O i�f.,e:x.^.ti5 Ur4i Tlc7itrrChen rN;uast rilitc ln' (sealablc)
940 Washburn Switch lade Shelby, NC 28150 yn 10/17/2022
Plty5IcaI Address.Ct15.i3nd Zip S tim• Cenirlcd'Well f'mur aul nt Rrcll Miter Date
Cleveland RI'.VjN97fgg this lfirin. I herebP coin•that lire wellrs) trrs tit ere.r abandoned ut
C'treusq latcelldentifirnhit Nu.WINi accordanc•r with L?4 AFC:-lC 0 C•0100or 2C.0200[Nell CviniTichuti Strinclurifs
arld thin a cola,of-ibis recclyd/an beat provided to/ire n'cll owner.
$6.I atitude and longitude:in dcgrccslminutcslucnnds or decimal degrecs:
Strts•dl fchl,tale 1:11.1 any is Sltliicrl%l) 9.Site diagram or Additional well details'
You lout•aic the back of this passe to provide additional well site details Or well
35.324701 n 81.635839 W abandonment details. Yew inay also attach additional pages if necessary
CONSTRIK-tION DETAILS OF WELUS)BFING ABANDONED SUBMITTAL tN4TR1JC'TiONS
Aif dr arell carn7rlc•iiju rccvrdl..)i;JFYTJftbh-. hoe rriirlople b etiimr ar reran-i ntrr+,rrl.'h'
melt,•ONIA'uitlir'.ew.wim! ,r.<r:�urnr'Jbcur<hluc.c-at.iurrcmreld'lrtlrum_1Lnrr. loa. For all ♦nett.• Submit this full Lvlltun 30 days of completion of n'CII
fie.writ[ll§:
TW-01 abandonment to the follnwirag:
Division of Water Resourcm,Information Processing Utut,
61P.Totaln•dl depth. (ft.j
43 I617 Mail Senice Center,Raleigh.NC 27699-1617
il)b.For lnicelhhrh Wells: Ju addition to warding the form to the address in l0a
6c.Boreholedhnncter:2 (in.) above.also submit One copy of this form ssilhin 30 days of cmnplelion of well
abandonment to the fallowing
6d,%ter level borne ground surface: 29 (ft.) Division of Water Resources,Undergmund injeaxion Coutnhl Prtigram.
1636 Mail Service('enter,Raleigh,NC 27699-lft36
6c.Outer easing length(if Imown)• 33 (fL) Itic,Fn n ,r Water Sunly iohxtion Yells: in addition to sending thefour:to
the address(es) above. also submit One copy of this form within 31) days of
completion of%sell abanduumant to the courtly lr_attlt deparinicrn of the county
6f.Inner casingitultin;,teuyKh(if knonn); (ft.) where abathipt cil,
6-..Screen length(if latosvn):10 (ft.)
I
Falm OW-an North Cuic-bro 1hLurnr)cru of Em iro:n icia urd NaEttial Resotlmes-Die ision of Water ltcsoulccs Re,iced August 2V13

WELL ABANDONMENT RECORD For ltnenwl L1w ONI.1':
This form am be used.for single,or multiple wells
1.Well Contractor Information: WILL ARANDQNMENT DETAiiLti
Stefan Smith 7a.Numbcrofnellsheingabandoned: 1
Well Coronae=.or Name(or 1.61 wmier p_isoicdll abaatikuriu6%%tl oa his-ter ptepen)) For rrnlfnpIc ft(tectine a' r,ti'n-Welrer srr;urA• ue.lhs ONLY wab ti' tunny
froeftr.Yl 4AI'lrommellf.1vn1 C111 stthwir rNtu fimil.
i
3576A
NC Well CnrrtradnrCcniilcalinn plun#+er 7b.Appmx)matc volume of staler mmaining in
SAEDACCO Inc FOR WAnit$UPPI.I'WELL,5QNi.Y:
C'anfr,t i)-Manic %,fYI)c of disinfectant used:
2.Well Construction Permit t):,
Lasl 4r11 applIcuble rrell twrAPliX rl.r-Cmair.Vale.1 JrfW82'.hlterYjm?.ek.l f/kmrafll 7J.A[Ilt►LnI of Jiainfcetaut nseJ:
3.Well use(chec)tn•ell use):
Wier Supply Well: 7c.Scaling materials used(check all that apply):
❑AgAzultutal ❑hlunicipabl"ohlic F1 Ncal Cement Grout rk Sctaonite Chips or Pellcis
❑(leothcrm:d(HcatinglCoolin;;4upply) ❑Rcsidcnti:ll Water Supply(jingle) ❑Sand Centclu Grout ❑ Dry Clay
❑htdnstri:dl(:omnlcrcial ❑Residential Water Supply(shared) ❑Coucrele Grout ❑ Drill Cuttings
❑1fli •tion ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: U Bemlonite slutly U Other(explain mWer 7g)
DoMunitorine ❑Recover•
Injection Wcll: 7f,For each ortterial sclectcJ above,luvis'ide amonut of materials nscd:
❑Aquifer Recharge ❑Gwundi►micir Remediation
❑Aquifer Storage aryl Rccovety ❑Salinily Barrier
❑Aquifer Trst ❑SlonmcaterDminam Bentonite.:51b ,Wtr:gal.
❑Experintetual Technology ❑Subsidence Control 7g,Provide a brief description of tlnc abandonment procedure:
rJGeothermal(Closed Loop) UTntcer
Pour hydrated bentonite pellets
ClGeotle<n»al(Ht.itinu•'Coolin;;Return) ClOtlicr(ex lain mxier.„)
4.Date srcll(s)ahandom_rt: 10-10-22
53.Well location:
PPG liLivtiv(xo«_1 7�f �i�i^` 1 l)fZri
racilitj-Xhrn:rNam1w rxiMy Ina(irappli--fblc) S.Certification; , Ditivia-S lG
940 Washburn Switch Rd. Shelby, NC 28150 --iQL!.��7W""` 10/17/2022
PIi}'sisal Address.Citi:;rnrt Zip ti'�nre:b Certificd Well t,krlrrrBGclr ur V/61(,hsmr Mile
Cleveland Br stqurt{�1hts b...11l. I hembt'rerr,'ft'tltru dw we•11rp,9 tars orere,r tibmidrnted:tt
Casnul lintel ldanlif6ali m No.(111191 uccurrlultco will?IJ:I aC:;•IC'OX,0100 or 2C.1120 rr E1!Cint,ilnfchbn SPondards
and tkaf a copy ol'this rrc orcl hens beery pror•itied io lire 1r•cll oa'tter.
Sh,I»ltitude and longitude In or decimal degrecs:
Ifln•e13 rw1d,itite Lof mig i—mificki-i1 9.Sitc dia►gratin or additional?Yel)details:
You may use the back of this page to provide additional well site details or well
35.324359 n 81.635213 �1' abaiduu rleut details. Yon IlinS'also attae h additional paloRs if itecessan.
MNSTRUC"TIQN DETAILS OF W'E:LLM MEIN(:ABANDONED 5 TRINIMAi.iNSTRLICTiQNS
affode it r1)rnta4lrltr isre frrcrrd(!o tI 0114JI(Arr. Feu•nntlupie hyecriore rr'rron-u•rttrr.nrppir
N'B1lY U:VLI'r17f11 riY'.1t1Ule rvA.clTwY'f1R'f�rAM14rrt.4iritarvlf.f an cure srrtnri!rArc'tuner. 10a. For all WeEm Submit [his mail within 30 days of eompiction of well
6a.Well IDi TW-02 abandonment to the following:
Divisiun of Water ReYourcm,Information Processing Unit.
61►.Total well depth: 30 00 1617 Mail Scnice Center,Raleigh,NC 27699-1617
Ulb.Far lnleellim Wells: 3n addition to sending tlt±,form to the address iu l0a
6c.Borcbnlc Jlanrctcr,1 (ia.3 above.also submit one cope of this forn within 3(1 days of completion of hell
abluidoulnern to the rallowilt":
Division of Water Rvionmes,Guder•}(round injection Control Progratu.
tid.Water level he[nn gnu►and aUrfacc: 24 ff4} 1636 Mail Senice C''emer,Raleigh,NC 27699-1636
6c.Outer casing length(if Imown): 20 (ft.) I Oe.Fnr Wikj�r•Sr_ rm '• to lectionr Wells: 3n addition to se►idim,the form to
the address(es) above. also submit one copy of this form within -10 days of
completion al'well abandonment to the cormly health dcpartruem or the count;-
(if.inner easilh'tul►ing length(if lawsvn}: (ft.) w here ghindoncd.
6g.Screen length(if lulosrn):10
Fauu ti1Y-3u Nonli Carolina De[mull mi of Ens-irl;tottefA and N:turol Rcsfmixe5-Leh LSla11 or W'BICf 1tC5GIlIR RCrLied AlLetiR 2.013

- i
WELL ABANDONMENT RECORD Fir trrenuilMwONIX:
This form Call be used for single.or mu_ltipl:wells
1.Well('nntractor Information: WF LI.ABANDONMENT DF:TAM;
Stefan Smith 7a.Number of hell,bcing abandoned: 1
Well CmAjaclor Name tot%tell mttwi rvtsowilh Axiwilo11hig UCII am hsl her piapcey t rev' rndnpir 01leL'1i(Al1 ur, NVW-wares- 3trpp r nV;l3 0,VL)' 'wed) xa8ne
l avat+micural ea'arl,G„+art•+tt)r,p rrnrss•:ftvur(me fain.
3576A
14C%V01 CowraclorCcrliftt:aims 11mrbci 7b.Appnrsimatc solmne of»attr lrmaining in nell(s)?1 (xuL)
SAEDACCO Inc FOR WATER SV1'Pi.V WEI.L.S ONLV.-
00113ran)Name 7c Type of disinreetant used:
2.Well Construction Permit
Ltsrarlf d,JpfleJl%1C Ivelf;wrmL1'(j.t•.C oared'.Stul<.)nnarce.Lgrdiorr.Nlr.i il.frtnleu
7d,!lrnount of disinfcttant uses:
3.Writ use(chedi well urc):
Water Supply Well: 7e.Scaling materials uxtil(clicch all that apply):
❑Agricnhpml ❑hitmicip dii'ttbtic ❑ New Ccrilm Grow 6d Berdonitc Chips or N-11c15
❑(irotltmud(Heatirh'Caolitta Supply) ❑Rcsiden►i;d�Vatrr.Sttpph tsinAle) ❑Sarin Certtela Grunt ❑ DivCLn
❑hidumbUComntercial ❑Residential Walcr.Snpph•tshmed) ❑Concrete Grout ❑Drill Collings
❑lrri t•lion ❑ Specially Grout ❑Gra%vl
Non-Water.Supply Well: G ijenlonite slurry C1 Other(explain alder 7g)
wMauilorinc ❑ ccavery
injection Well: 7f.For cacti inalcrial selected above,provide amount of materials itself:
[]Aquifer Recharge ❑Groundwater Rentediation
❑aquifer Storage anxl Recovery ❑Saliuily[harrier
❑Ayalifcr Tcs1 ❑Stomnsatnr l]rsiecler
Bentonite.:51b ,Wtr:gal.
❑Experimental Twhualogy ❑Subsidewu Conutul 7M Provide a brief description ofthe abandonment procedure:
❑Geothermal(Closed Loop) UTraccr
Pour hydrated bentonite pellets
C7Gcothemtal(Hrttinp�'Coolin>?Return) CJOttwr(c.� lain antler 71t)
4.Date sells)abandoned: 10-10-22 .F
id.Well location: O C T 2 8 2022
PPG Ii fori-rta';2-m %�f�^353€::land
S.Cer•tlficatimt; ]
rlciltlpiQwnrNrutk rxiriyMilltifappli;iblc) t� DV Q,'••rf`0-G
940 Washburn Switch Pd. Shelby, NC 28150 fL ' Vj 'U7 10/17/2022
��l ----- ,i.
Phesical Address.Cie).and Zip C :I arc Ct:niru W'-11('auttnt'.lar nt V,ell outscr Uate
Cleveland 111..sjgjmf{g fires form, I herehy rertlft'that the wellrs) tress(here/ abandoned to
(irutth flircel ldmifirtikin No.(VINt oceurdwire irith !J-1 X(."-i1.'02C ,010U ur 2C.0J))0['elf f.il,l,�lnrcf;ou.Cftnuietrds
and that a cupr oJllris rcrorJ hos hc:ex proriclee!!o!!re n•cll t>uner.
Sit,Latitude and longitude in dcgrccslrnirurtcsJsecnatls or decimal degrecs:
Iiriscll rwid,one L omtg is Salllcict-4l 9.Site diagram or additional well details:
You matt'the the back of this page to provide additional%sell site details or well
35.324359 1\ 81.635213 W abaulonnteut details. You ray alsa attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELId5)BEING ABANDONED -LTBNfrfTAi,fN5TRU .TiONS
Irfudc trrN rurverncLw:rner,raf."m f anuJra4Jr. Rev nuslople Biiecalnu(.v n„n-ucuer nipp1r
nellrO:\'Li'mtr.4 rfr .,,le,Irelavarnenr•r4:4eurelorcn.nr.icw cur:mjbirnl wrr'lom. 10a. For All Wells- Submit IhLS fund w•illun 30 days of completion of well
6a.Well IDi1:TW-03 abandonment to the fallowirt,,:
Division of Water Rewurees,Inft►tmation Processing Unit,
fit►.Total swell depth: 35 (ft,) 1617 flail Service Center,Raleigh,NC 27699-1617
Wit.For inieetlon Wells: In addition to seirding tlh foriu to lite address ill l0a
6c.Bomhole dianichr.I abosrc.116u slibluit our COPY of this forn sviihin 30 days of completion of well(in.) abandomuem to tire fallowing:
6d.Water h vel helms gr itund mirfam. 20 (ft.) Division of Water Resources,Underground Injection Control Prugr rtu.
1636 Mail Service(.enter,Ralcigh,NC 27699-1636
fie.(lutcrcasinglcn;,tb{if Imonn): 25 (ft•) I[tc.For W rr,S+r11,11e in inn Vrlls: In addi(ion to 5;►Iding the form to
the addresses) above. also submit cnle copy of this forn widiin 30 days of
cortipledun al"%sell abandonment to the county lruhli deparinicm of the County
6(.Inner t:aainl:/tnbing length lit known): (ft.)
wltcrc abandoned,
6g.Scrm"length(if knossn)-.10 (ft.)
i
Fomi G1V-,tl North Caiotiro Depnimm of Em hoameni anal Natural Re5mv cs-Division of Water Rcsowees Rcrtscd Aucust 201

WELL ABANDONMENT RECORD For trilmml V_w ONLY:
This form can be used.for single or multiple[sells
1.Well Cmrtractnr Information: WELL ABANDONMENT DFfAiL8
Stefan Smith 7a.Number ofnells being abandoned:
1
Well Ce aracior Nnme(of%,dI owwr pC1501L•t11)91mi bili11g dell all lltud!er prepaij 5 riu Irorfople IAlCcrimr c1.• lma-metro. sl:ppfr• ++ells ONLY wob Mw mane
rr nrrnieotaa:rb�+:rai:rrrnrr:r,pea,wrr.tan5aor wig lr,rl,i.
3576A
r Al.Approximate volume of[rater remainiu;;in xcll(sT?1 {;aL>
NC Well COminclorCcniJc;ninu Nnn-bcr
SAEDACCO Inc FOR WATER SUPPLY WELLS 4,1NI,V:
Cnn4rany Nornc 7c.Type of disinfectant used:
2.Well Construction Permit H:,
Lw 4dl"p11:41t•uble well rworatr(j._.C ua in State.)oriouce.bytuirjit eic.1(JA!uibrr
7d.:lmount of disinfectant used:
3.Well use(check.well use):
Water Supply Well: 7c.Scalia-matCrials uscil(citcclC all that apply):
❑Agricultural ❑hdunicipaliPublic ❑ Nan Cenicut Groat M Bemonitc Chips or pellcls
❑(ic(idtcr•nvll(Hc lt6rs 'Caulin3$uI}pl}) ❑lIccidonti l Water Snppty(Sincic) ❑ Sand Ccuterit Grout ❑Dn Ckm
❑hidnstrialiCgmniercial ❑Residential Water Supply Ishated) ❑Concrete Grout ❑Drill Cultings
❑ itigation ❑Specialty Grout ❑Graved
Non-Water Supply Well: U Beritonite Slut)• rl Other{;explain under 7g)
��loniloring 131keem-er•
Injection Well: 7f,For each material selected abovT provide amount of materials used:
❑Aquifer Recharge ❑Grruminater Reniedt:itian
❑Aquifer Storage aiYJ Recovery ❑Salinity Barrier
❑Agnifcr Test ❑Slaciuttialrr C)rahcage
Bentonite.:51b ,Wtr:gal.
❑GipL'tliilumal Technal a ❑Subddewe Control 7g.Prin-ide a brief dmiription of tiic abandonment primedure:
i 0codternml(Closed L.00p1 iiTrlcer
Pour hydrated bentonite pellets
CIGLrodterntal(Heatinrt'Coolin Return) C70dtcrtcxplt3inm3der era
J.D:Itr.rvell(sl db:uadnocd: 10-10-22
tj ,�& t t� p'
9y rnt
i 17f yi
Sa.Well location: ,.•
w
PPG L
rudIilr:r(hvmrN;rw4 r}.iliayIU'(ifappliablc) S.Ccrtlficntiod: it1F>.o„r�;DI !,r4s�
,nth(Jns
940 Washburn Switch Rd. Shelby, NC 28150 L— i4,y 10/17/2022
,)--1�--
Pimical Address.City.and Zip .C:-s spas...Ce:tirsd WL31 Coutmcwt or IVOI Owl= D IC
Cleveland Br.v{c:rrrng this firrim, I hemtj-cerYrh•rhnr lire wellfs) was ruerer ahamfolied err
C'auuy 1 imel Wni ifdctakni No.(PIN;r Decor Iance w ille 1,:J`.f:=1C'Olin,0100 or 2C.0200 fF ll Can sinrctiori Skmdards
and that a cop[�71ris rccc�r<llrrrsbeerr f+rot idler!to fire s+•ell utterer.
510,1.1titode and longitude:in ddy;rccshnirducsfsccnnds or decimal dcgrccs:
Siftscl?Fntd,ow ItIlAing is static l-Jf 7.Site diagraw or additinnal well dclail5:
Yon❑lit}'use the back of this page to pio�•ide additional well site details or well
35.325085 N 81.635974 Y�' abandaunteut details. You rimy al o attach additional pages if necessary.
CONS'rRll(:'r1ON DETAILS OFW1 LL(Sl BEING ABANDONED S(1BINiiTTAi.iNSTR(iC.TtUXS_
:rrfade null eorxrr_icrinr n.mrN+)if otynh hht Ivv nrtdr{nit•bjecdem or mei-n•akr wrpplr
trolls•ONLY orui rlk.Vale:v.K+f.arfherir!i:ur<hnrr:fenr.t+m dui;:lilarrl rpre;tinrr' lUu. For All Weak' Sublmil this lbrnt within 0 days of compaction of welt
63.Well ID#:TW-04 ab;anddnmcm to the following:
Division of Water Rmuurcer,Information Processing Unit,
Gb,'total well depth:
30 1617 Mail Service Centel-,Raleigh,NC 2769'l-1617
{fl.)
lUb.Ivor iniccNon Wells: In addition to�.nding Elie forat to the address in Ma
Coe.Dorthole diameter:l above,also sttbntit one copy of this form within 30 days of eompleiion of►yell
(ill.) karldotuuetu t0 Elie falloWfi g:
till.Water level bc[nvs rnun[t surfac0: 18 (ft.}
Divislanof Water Resources,Underground Injection Coolrol Program.
F 1636 Mall-Service Center,Raleigh,N('27699-I636
fie.Outer easing len-,th(if Imoe n): 20 (fat Inc.For Water Sur i►lu C ire'' inn Yells: Tn addition to Sending the forms to
the address{es) above. also submit one copy of this form within #U days of
Conipletidn 01'well abandomnicnt to the COimly lEcahlr dcpannicru Of the C0110V
a•hcrc nbaridlmz`d.
(if.Innercasin;;Itubing length(if knonn): (fat
Gg.Screen length(If knonn):i0 (ft.) i
Fa all GW-tu Non h Carolina Depaimictu of Em irommasit and Natural Resen:wcs-Dii isio1r of Wmcr li No1r0.'Ci t?e,Lied Augusi 2p l