Cleveland_Well Abandonment_20221222

WEJUL AISA INJULKV1YJL1'NT 1?,hUU1W For Internal Use ONLY:
1.Well jpontractor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed=Loop Geothermal Welts having the same
Well Contractor Name(or ell owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: C
NC Well Contractor Codifiicatio{npuuJmber 7b.Approximate volume of water,
e i remaining in well(s): 1 (gal.)
rn/ 'Ci ,1p!��• i//(� FOR WATER SUPPLY WELLS ONLY:
Company Name
x 7)t p� 7c.Type of disinfectant used:
2.Well Construction Permit f-� Q
List all applicable well construction permits 6.e.U1C,Couno;State,Variance,eta)(/'kmavn D
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply
❑Agricultural ❑Mu '' pal/Public ❑Neat Cement ut ..a ,,,- , , entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Iestdential Water Supply(single) ❑Sa d Cement4ht; Clay
❑Indtistrial/Commercial ❑Residential Water Supply(shared) Concrete Grout j ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout �-1:7r �'129 2022 ❑Gravel
Non-Water Supply Well: ❑Bentonite a er(explain under 7g)
❑Monitoring ❑Recovery "F"' ���+s� ���P��C` ��op
Injection Well: 7f.For each naterial serected2C* rovide amount of materials use :
❑Aquifer Recharge ❑Groundwater Remediation G N7///7 / � I'��j�/I {�� �O Vile- ?�
❑Aquifer Storage and Recovery ❑Salinity Barrier // I f j,P Y �!
❑Aquifer Test ❑Stormwater Drainage
ClExpetimenta)Technology ❑Subsidence•Control
7g.Provide a brief descriptionlof the abandonment procedure:
❑Geothermal(Closed Ldop) ❑Tracer 1.
❑Geothermal(Heating(Cooling Return) ❑Other(explain under 7g) V 6 /v�/1'J/ 19
I d�- -aa b Died e�9isA PwA 9 &Ie,
�1.Date well(s).abandoned: i
.
S;r a.Well
>°l-ex Coi'p1�lyl
Facit' /0v)nerName Facility #(ifppplicable) 8.Certifrcation:
Physical Address,City,and Zip Signature of ertified We Contractor or Well Owner Date
e����" " By signing this form,I hereby)!certjfy that the well(s)was(were) abandoned In
County Paicel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
•5`b:Latitude and longitude in degrees/minutes/secopds or decimal degrees: �; ,
(if well field,one lat/Iorig is sufficient) 9.Site diagram or additional well details:
vINR) �f�s^f�aIr 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.
CONSTRUCTIONIDETAH S OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIOINS
dttachwellconstructionirecord(s)ifavallable.FormultipleInjectionornonn-%wersupplywells.
ONLY svith the same c/nstnrctlon/abandonment,you can submit one form. j
10a. For All Wells: Submit this form within 30 days of completion of well
61r.Well M#• ( � abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b:Total well depth:. .0 (fk) 1617 Mail Service Center,Raleigh,NC 276994617
IOb.For Infection Wells: Inaddition to sending the form to the address in IOa
6A BUrehole diameter: /0 (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 Resour,,.i Underground Injection Control Program,
1636 Mail Service enter,Raleigh,NC 276994636
6e,Outer casing length(if known); (ft) 10c.For Water SunnIV&Inf I ction Wells: In addition to sending the form to the
address(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
6L Inner cosing/tubing length(if known): _(ft.) abandoned. '
.6g.Screen length(if known): (ft.) i
furor GW,30 North Carolina Department of Environmental Quality-Division of Water Resou Ies Revised 2.22-2016

WELL ABANDONMENT RECORD [For Inlernal Use ONLY: f
I � -
1.WcI1 Contractor Information: WFL[.ABANDONMENT DETAIIIS
—well
rr 1�E(I UfZ.r'/L(' rTiZ 76.For Geoprobe/DP.T or Closed-LI op Geothermal Wells having the same
W ell Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
27 -30
NC Well Contractor Certification Number 71b.Approximate volume of water remaining in well(s): --(gal')
P
Cascade Drilling LP FOR WATER SUPPLY WELLS ONLY:
Company Name lc.Type of disinfectant used:
2.Well Construction Permit N:
List all applicable Hell construction permits(i.e.UIC,County,State,Variance,etc)iftnown 7d.Amount Of disinfectant used:
3.Well use(check well use):
Water Supply Well: ('7�e S�ealing materials used(check all that apply):
❑Agricultural ❑Nlunicipal/Public �a.7VCat Cement Grout �Bentoaite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ ry Clay
❑Industrial/Commcrcial ❑Residential Waicr.Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 79)
❑Monitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater;Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heatin Coolie Retum) q�lbthcr(ex lainunder7 )
a
4.Date well(s)abandoned:
Ss.Well location: a
Abermarle Corporation .+
Facility/Owner Name Facilitymli(ifapplicable) 8.Certification:
1�#,,;�,��°snn Pros.
348 Holiday,InrtDrive,Kings Mountain,NC 28086 C dQ/ OG /f- 2 -1 Z
Physical Address,City,and Zip -
Signature of Certified Well Contractor or Well Owner Date
Cleveland
County � By signing this form,I hereby certify,that the well(s)was(were).abandoned in
Paicel Identification No.(Pnq accordance with I5A NCAC 02C.Q700 or 2C.0100 Well Construction Standards
and Thal a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i,
(if well field,one lit/long is sufficient)
9.Site diagram or additional weUidetaUrt:
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.
t'ONSTRUMOI N DETAII S OF WFLL(Sl BEING ABAIN•DONED SUBMITTAL INSTRUCTIONS],
Attach wailconsiructionreeord(s)Ifavallable.Formultiplein)eclionornon-xnrersupplyxelis
ONLY with the same construetion/abandonment,you can submit one form.
10a.For All Wells: Submit this;form within 30 days of completion:of well
6a.Well ID#: S t( abandonment to the following:
+ Division of Water Resources,Information Processing Unit,
6b.Total well depth: (n) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Inlection Wells:'In addition to sending the form to the address in 10a
6e.Borehole dlameter• (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: (g) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
1 ;
6e.Outer easing length(if known): (n) 10c.Fdr Water Suooly&Iniecttrin Wells: In addition to sending the form to the
addresses)above,also submit one;copy of this form within 30 days of completion
of well abandonment to the coim* health department of the county where
t 61.Inner casing/tubing length of known): (ft.) abandoned.
6g.Screen length(If known):
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I
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1
WELL ABANDONMENT RECORD
Par Internal Usa ONLY:
1.Well Contractor inrormatlon: WFI I ARANDONMIAT DETAILS
£/�F CjZI:✓�� 7r 7a.For Genprohe/DPT or Clnred-Lot p'Geothermal Wells having the same
�••+r Well Contractor Nome(or well owner personally sbandnninRwell on hit/herpmpeny) well eonstmclinn/depth,only I OW-3dI4 needed. Indicnle TOTAL NUMI1EIt of
7,70 wells nbandoncd: 6 -1
A
NC Well Contractor Certification Number 71).Approslmale volume of water reinalning In well(Q: (PI-) "
Cascade Drilling LP FOR WATER SUPPLY WELTS ONLY:
1�
p- y Coto en Name 7a Type of(1Hlnfcclanl used: �
n
2.Well Construction Permit(1:
List all applicable%wit con trucaian prrrnlis(f.e.UrC,Caunq•,Slate,(arinnre,rim)trknnna
7d.Amount of dlslnfW21111 used:
3.Well use(check well use):
Water Supply Well: 7a Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public Neat Cement Grout Aentonite Chips or Pellets . .
OGcothcrmal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay'
Qlndustrial/Commctsial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttingti
OIrrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Scntonite Slurry ❑Other(explain under 7g)
❑Monitoring QRecovcry
Injection Well: 7r.For each matcrlal.selected above,•provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remcdiation
❑Aquifer Storage and Recovery ❑Salinity Harrier
❑Aquifer Test ❑Stormwater Drainage
OExperimental Technology ❑Subsidence Control 7g,Provide a brier description of the;abandonment procedure:
❑Geothermal(Closed Loop) OTracer
Ockothcamal'(11cat-ihStCoblingReturn) Mother(explain under 7g)
(3 7 rt'r(1
4.Date well(s)abandoned:
Sa'.Well location: 1'n r r ar
Abernade Corporation
FacltylowmerName Facility lDN(ifepplicable) 8.CertiIIeation: v�;l•ftF E`,il�fi r!•+'S�'•`��O
348 Holiday Inn Drive,Idngs Mountain,NC 28086
Pbysirul Address;City,and Zip Signature of Certified Well Contractor or welt(honer Data
Cleveland By signing this form,1 hereby cernAl that the well(s)was(were)abandoned in
County Parcel IdendficationNo.(PIN) accordance wlth.lSA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude mud longitude In degrees/minutes/seconds or decimal degrees. j
(Ewell field one IstAong 1.su(fiefeat) 9.Site diagram or additional well deialls:
W You may use the back of this page to, additional well site details or well
N
abandonment details. You may also attach additional pages if necessary.
CON.TRUCTIONPETAILS OF WELhIS)BF AAANDONF.D §UBNITTAL INSTRUCTIONS
Altarhwellconrrrucrinnrrtord(a)IJarotlablr.Formuldple injection ornon-waieriupplyhWLI
ONLY with the scone eanstrucliw✓abandomnent,you can submit one form.
o�\� 10s.For All Wells: Submit Ibis form within 30 days of completion of well
61-Well IDN:� K ` abandonment to the following:
Division of Water Rcsourcles.Information Processing Unit,
6b.Total well depth: (rt.) 1617 bran Service Center,Raleigh,NC 27694-1617
lob.For Infection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6a Borehole diameter: (In.) abandonment to the following:'
bd Water level below ground surface (ft.) Division of Water Resources,Underground Injection Contra)Program,
1636 Mall Service Center,Raleigh,NC 276"-1636
i
10c.For Water Suooly&Ili lcedou Wells: In addition to sending the form to the
6e.Outer easing length(If known): (ft l address(es)above,also submit one copy orthis f'onn within 30 days orcompletion
of well abandonment to the county health department of the county adtem
lye abandoned.
6f.Inner easing/tubing length Of known): M)
6g.Screen length(If known)I (ff.)
i
I
Prom DVl•]0 Norib Carolina Department of Lnviroamental Quality•Dividon of Water Resources Revised 2-
22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY ! i
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
C//} G�/J.t r J n. 7a.For GeoprohemPT or Closed-L op Geothermal Wells ha t same
r
Well Contractor Nome(or well onrcr personally abandoning well on hWher property) well constnretion/depth,only I GW-30 islnccded. Indicate.TOTAL NUMBER of
wells abandoned:
_2730 t4 1
NC\Yell Contracinr Cenifiwtion Number 7b.Approximate volume of water remaining In well($): (gal-)
Cascade Drilling LP FOR WATER SUPPLY WELI S ONi,V:
Coutpany Name 7e,Type of disinfectant used:
2.Well Construction Permit 11:
List all applicable rvrll construction permits(Le.UIC,County,State,-Variance,etc.)fkrutim
7d.Amount of disinfectant used:
3.Well use(check well use):
(
Water Supply Well: 7e.Sealing materials used(check all,that apply):
❑Agricultural ❑Municipal/Publie W Neat Cement Grout i (Dy Bcntonitc Chips or Pellets
OGcothctmal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commcrcial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑itri"ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bcntonitc Slur
ry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well:` 7f.For each material selected above,'provide amount of materials used:
❑A,quifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test OStormwater Drainage
,❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) A61ther(explain under 7g) r K lc�
LZiiV —U
4.Date well(s)abandoned:1 1—(7
ncr 2 2022.
5-Well location:
AbermarleCorporation fA+, ,a•"�"�
Facility/OwoerName Facility MO,(if applicable) 8.Certification: ��'���
348 Holiday Inn Drive,Kings Mountain NC 28086 7 j
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Cleveland By signing this form;I hereby certify that the weA(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 9.Site diagram or additional well details:
You may use the back of this page io provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(Sl nEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)lfavallable.For muldpleinleclionornon-watersupplywelh
ONLY with the name camtruetion/abandonment you can submit oneform. 10a.For All Wells: Submit this form within 30 days of completion of well
OiL.Welli IDMIt. P.,m a abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: . (Q,) 1617 Mail Service Center,Raleigh,NC 27699-1617
- n
ION For inlectlon Wel12: In addition`to sending the form to the address in IOa,
6a Borehole dlameterr (InJ
above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d Water level below ground atitiaee (1t) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636.
6e.Outer casing length(if known): (Rt.) 10c.For Water Supply&llnlecdon Wells: in addition to sending the form to the
address(cs)above,also submit one copy of this form within 30 days of completion
AlMk of well abandonment to the courity!health department of the county where
abandoned,
6f.Inner easing/tubing length(If known): (Rt-) f
I
t •
6g.Screen length(if known)- - (R.) 4
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources:' Revised 2-22-2016
I;
��_ mo —

fWELL'ABANDONMENTI RECORD For Internal Use ONLY:
"7_4k
1.Well Contractor Information: WELL ABANDONMENT DETAILS
i
a eek-674.vt' 7a.For Geoprobc/DPT or Closed-Loop Gen thermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hwher pmpeny) well consuuetion/deplh,only 1 GW-30 is noel e . Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining In well(s): (gal,)
Cascade Drilling LP FOR WATER SUPPLY WELLS ONLY: I '
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit 0:
Lki all applicahk wril construction permits(i.e.UIG County,State.Variance,etc.)fjknolm _
7d.Amount of disinfectant used:
3.Well use(check well,use):
Water Supply Well; 7e.Scaling'materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic 4-Ncat Cement Grout �Bcntonitc Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply.(single) ❑,Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared)` ❑.Condreto Grout ❑Drill Cuttings
Olin lion ❑Specialty Grout ❑Gravel
Non-Water Supply We1i: ❑Bentonitc Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Wen: 7E For each material selected above,provide stnount of materials used:
❑Aquifo Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stocmwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Conlin Retum) Other(explain under 7)' O�Y
4.Date well(g)abandoned:
5a.Well locatiow ¢
Abermade Corporation N' O_VJ3 .I
Facility/OwneiName Facility lDq(ifapplicablc) 8.Certification:
348 Holiday Inn Drive,Kings Mountain NC 28088
Pbyiical Address,City,and rip Signature of Ccnified Well Conunetor or well Ownir Dot.
Cleveland
By signing this form,I hereby certi that the well(s)war(rime)abandoned in
County parcel Identification No.(PIN) accordance with I SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude In degrees/minutes/seconds or decimal degrees: and that a copy oflhis record has been provid t ed to the well owner.
(If well field,one lat/long is sumeient) 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 ailiiitional Pages if necessary.
I;
CONSTRUCTION DETAILS OF WEL (Sl BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach wellconstructionrecord(&)ifavallabie.For multiple injection ornors-imte»upplynriis j
ONLY wlth the Jame coutruelian/afaadonmenr,youcan submit onejanri. lots.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#. abandonment to the following:
i
Division of Water Resources,Information Processing Unit,
6b.Total well depth: _Aft.) 1617 Mall Service Center,Raleigh,NC 27699-1617
lob.For Infection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter:�(]n•) 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: (It.) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
6e:Outer casing length(if known): (ft) loc.For Water Suooly di Inlecdon Wells:;ln addition to sending the form to trio
A address(es)above,also'submit one copyof this form within 30 days of completion
'J t of-well abandonment to the county health department of the county where
6f.Inner easing/tubing length(If known): (tl) abandoned.
i
fig.Screen length(if known): IN,
Form GW-30 North Caroline Department of Enviidnrcenml'Qucilty_Divlsfan of Water Resources
r Revised 2-22.1016
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