Cleveland_Well Abandonment_20230327

WELL ABANDONMENT RECORD For Intemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILSI
Jeffrey Grant 7a.For Geoprobe/DPT or Closed-loop Geothermal Wells having the same
Well 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
4328-B wells abandoned:Three
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '1 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
WM0301267
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout I Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: - 7f.-For each material selected above,provide amount of materials used: _ .
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
0 Aquifer Test ❑StormwaterDrainage Bentonite 15 pounds
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Fill the entire length of the borehole with bentonite.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
3-20-23
4.Date well(s)abandoned:• pp
5a.Well location: MAK 2 7 lULJ
Concrete Supply Co. LLC 00-0-0000012451
S--•- Pramwng pi:
Facility/Owner Name • Facility ID#(if applicable) 8.Certificati m v r;rOG
200 West Graham Street, Shelby, 28150 3-20-23
Physical Address,City,and Zip Signal a of Certifiedontract Owner Date
Cleveland 2547102107
By signing this form, I hereby certify that the well(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 lat/long is sufficient) 9.Site diagram or additional well details:
35.290129 N 81.542662 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.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS -
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you con submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: B-1, B-4, B-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 11 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1.5 (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 7 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
7 10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 4 (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JeffreyGrant
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well 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
4328-B wells abandoned:Two
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '1 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
WM0301267
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout Al Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑ Drill Cuttings
0 Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
(Monitoring ❑Recovery
Injection—Well: — " -- - - --7E For each-material selected above,provide amount of-materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite 10 pounds
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Fill the entire�leng$hof the borehole with bentonite.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
t'
4.Date well(s)abandoned: 3-20-23 MAR 2 i
2073
5a.Well location:
Concrete Supply Co. LLC 00-0-0000012451
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
200 West Graham Street, Shelby, 28150 _ 3-20-23
Physical Address,City,and Zip Signa e o ied ell ntractor or Well Owner Date
Cleveland 2547102107
By signing this form, I hereby certify that the well(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 lat/long is sufficient) 9.Site diagram or additional well details:
35.290129 N 81.542662 • 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.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: B-5, B-7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1.5 (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 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 1 (ft.) 10c.For Water Supply&Injection 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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 4 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016