Cleveland_Well Abandonment_20230428

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WELL ABANDONMENT RECORD For hint-hal Use ONLY: ,
This foim can be used for singte•or multiple wells !
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1.Well Contractor information: \ WELL ABANDONMENT DETAILS
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Scott aunt, Jr 7a.Number of wells being abandnncdL 1
• We1t'Cotitactor Name(Or w town=personallyab5mieni g%%diemliistlmrproperty) ' Far itadoatc fit,4'etiont Er rwra-nztrcr supple wells •ONLY wttL the sa'iie
eo s cnrrgeba do.'maent)ewercyansralniataaeform
4561-A
7h.Appmaimate volume of water remaining in well(s)9 (OPNC Well Co'ntractorCcnification-Nmtiacr
SAEDACCO Inc FOR WATER SUPPLY WELLS ONLY:.
Company Name - 7c.Type of disinfectant used:
2:Well Construction Permit li:, WM0301260,
Lat 00 nppllrmble weHp ruri?.(P.r Coutu,S&we:Miriam-4 Inieetiyu,etc)tf S•tauwlr • Id.A[mOtitlt of dlsinfectatit ttsrtil:
3.Well use(elmek.well use):
Water Supply Well: 7c Scaling inatcrials-used(cheek all that apply);
liAgfreulturat ❑JM unicipal/Puhlic• 011 Neat Ccnient.Grout C1.Ucntonitc Chips or Pellets-
.17Geothennal(llcatinglCooling Supply) ❑Residential Water Supply(single) ❑.Sand Ceittent Grout ❑Dry Clay
❑lndustrial/Comntcreial ❑Residential Water Supply(Shared) .❑.Concrete Grant. ❑Drilltiatings
Obligation . ' ❑Specirilty.Grout 0 Grniv'el
. Nou 1'Irater Supply Welt: Pt Bentonite Slimy • 0 Other(explain under 7g)
EtiMonitorine ❑Recovery
Injection Welt: ' 77f.For each material selected above,provide:amount Of materials used:
❑Agmif rRechar,'ge ❑GrouiidwaterRetitediaatlon Neat Cem.:4001b ,Wtr:30ga1. Sand Cem..:lb ,Wtr:gal.
l7AquiferStorageartd.Recoveiv ' l7SalnityBarrier •
Bentonite.:2001b ,Wtr:45ga1.
.❑Aquifer Test ❑Storm' terDrainage .
ClEvpetintenwl Technology []Subsidence Control 7g.Provide ii briefdcseriptlon of the abandonment inneedure:.
ClGeatlwnnal(Closed Loop) .°Tracer
removed.1" temp well; tremie grouted with bore grout to 20'
OGeothenml(lieatigatCooling Return) DOther(ex-plain under 7g)
then type 2 portland for the last 20'. of the bore hole
4.Date wells).abandoned; 3/23/23 .fz+o,,r:r+ .�at
Cs.
5a.Well tncation:
Celanese Ticona ;APR 2
2u23
FaeilityAUwtierNtutee Facility ID5 Cifappiicablc) 8:Ccrtlf[etilian:
3(,9us�t Itrt�r.ti��Pr. l:n
2525 Blacksburg Rd. Grover, NC 28073 C-Vit:0O4`/8/2023
Physical Address,City.dud Zip - Stgrttlinro of CaittIIed Walt Cot Clot or Well Owmr . Dame
Cleveland . By sigtir{g-thfs fbrtn, I hereby.certify that the n'e11(s)wa$(we'rw)alianda;red to
Comity Patr;el ldantifitittuNo.(PiN) imx,vniai cc with I5A.VCAC 02C.OIINJ.or 2C.01200 iVidlCutlsbuction Standards'
• ' - and draft a cop&ofthis record has been provided-to the well owner.
Sb,latitude and longitude•in degrees/minute's/seconds or decimal degrees:
(Irwin fa nd,otm:latlMng i$Sitfilicerl) 9.Site diagram or:additional well details:
You May use the back of this page to provide additional well site details or well
N W abaadomnteuldetails. You may alao-iwat:h additional pages if necessary.
CONSTRUCtION.DETAILS OF WELi.4S1 BEING ABANDONED SUBMTiTAL INSTRUCTIONS
atone itdl co,MarazCtiarr reerarel(Sl'If mat/elite."FLU'maifiplo Utircfian or ISJS a0•supply
wells ONLY u-fih the suite rouse rarrtonr'abrvulvrmenr,tart trim iipmit are f'onti ion .For All Wells: Submit this farm within 30.days of completion of well
6a.Weil mg:pDI-SB-S ;lbanddr niciit to the fallovvinG:
Division of Water ResnurriN,Infunnatitin:Procising Unit,
77 ((tt:) 16i7 M ril Service,Ginter,Raleigh,NC 27(99-1617
6U.Total well.depth:
10h.For Inleetfain Weals: In addition to sending the form to the address in Ina
.above,also submit one copy'of Ibis form within'30•day's of completion of well
6c.Borehole diameter:1! (in.} •abandonment to the following:
fed,Water level below'ground surface: 12 (ft.) Division of WaterResouries,Underground Injection ContmlProgram,
1636 Mail Service Center;Raleigh,NC2769J 1636
6c.Outcr easing tOe,For Water Sunnis.&infection Wells: In additlon'to-scnding the form to
fi 1 engh(rf[mown):); (ft.) the address(es) above, also submit.one cop} of this lam Within 30 days of
completion of well abandonment to the county health department of the county
61.Inner casiri'gfubing length(if lmawi•n): 67 (ft.) where abandoned,
6g.Screen.length(If known):la (ft.)
Fame GW-30 North Carolina Dcponmcnt of Environment and Natural Resources-Division of Water Rdiounes Revised August 2013

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i WELLABANDONMENT RECORD For kildnial Us;ONLY:. .. .
This forme=be used fOr single or multiple Iv-tit§ , .. .
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I,Well Contractor Informationt WELL ABANDONMENT DETAILS
Scott Hunt, Jr . . 7a:Nitmher of wells being abandoned: 1
. Wcktatitraeler Name(or nett OOtter peisenally abanioning nell.On liisdner prepcny) For nationfe. littedion or noin4oter juppb,- urdis ONLY %lib taus smile
consrmahmiabandamevit,AIN MR 570Mitit Pike fOrIn
4561-A • •
iitYcargiiior Ceti ilittinttNiiiitier 7h.Apprminiate yalittne of*at&reinaining in well(s)9 - .(gilt)
e ttaC
SAEDACCO Inc ' . . FOR WATER SUPPLY WELLS ONLY:.
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Company Name 7c.Type Olidisinfectanttiscd; •
2.-1•VISE.Constraction Permit(ii:, wm0301260,.
Liman opipheoble.tiellpentrio(Le.CWIllry,d57.041,.1,11.17iiitkA,bElt0100,. .rfi,1 I.,aLtalitl
• 7d.Amount of rdlsinfeetrint usedtI
3.Well use(checkwelliase): . ,
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Water Supply Well;• • 7.e.Sealing materialstised(Cheek:ill drat apply);
• ' 0Agrietiltitial CIMimiCipahl'ohlio.. Dl Weal Ciunctitcrolit LI BentOolle Chips orFellets
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1:10cOlketillai(DeatingiCooling Supply) OResidential Water Simply(single) , Li ISOlcfCMC91 Grad 0 Dry Clay
0 indoStrialiConinietcial• OFtesidential Winer Scoppv(muted) .CI•,Cbtietete Groat • 0 prill.Cintings
• Ofrtination . . . . . . • .'0 Specialty Grout CI Gnivel• .
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Noo•Water Supply Well: • Dl Peittanite Slimy Cl Other(explaiminder 710 •
- Midoithorine. ORecrieety
• Injection Weil: .• 7f..FOr each material selected Am*,provide-amount of:materials used: .
13 ilipifet Recharge . CIGniutichvater Rentedhition- Neat Cem.:400ib ,Wtr:30gal. Sand Cent.:lb ,Wtr:gal. .
•ClAquilei Stowe onititeetwery OSalinity Ranier .
Bentonite.:2001b iWtr:45gal,
- - 0Atistifet Tnst OStestmwater Drainage . • - - . „• - . .
CIEspedmental Teehuolom? . tiSubsideire Quittol 7g.PrOiride a liriarkscription of the.aliandonment.PrOgOuret
°Geothermal(Closed Loop) DTracer- .
removed 1" temp well; tremie.grouted with bore grout to 20'
• OGeothenual(FlotingiConiing Return) • ClOthcr(midain under 7g) • • • • • . . . ,
, • then type 2 portland f or the last 20'. .of the bore hole
4.Date well(s).abandoned: 3/23/23 • "
• • • R• 7::L_C.OE/tVt."."...1.,)
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Skt.WeE location; ,
•
zoza
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Celanese Ticona
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. .nility/cIvneeNtinte- . Facility lInd(ifapnlicablo) 8 Venlig-Et4On
2525 Blacksburg Rd. Grover, NC 28073 5'0.4cte-gi/ittL9/21,111!°fVflDVI'll/QIPr fla'C°6'51344F44/1j8/1:023
Physical•Address;City;and Zip. .Sipriluse o r Ci:d IOW welt Co.iti tar Ot Well OnTor Doi:
Cleveland _ • • •. . . A>,Ogottig nn.i.form,'.1 hereby cerdA tied the we'll's)Feu(were abandoned in.
County Parrellantiffeatinni4o;VIM accordonen with ISA NCAC OX;.010..or 7C.41200 rVell Cousin-010n Starnbirds'
• • and dun a.cmiyafiiiix iecordhas been:provithid(OlbeiVell owner.--
b.Latituderand larigitude.irt degrer4fmtitu*Acconds or decimal degrees:
(if•Well fiat,one hailisia is siciri*A) • . 9.Site diagram or additional well details: -
. 'You may use.the haat of this page to pros additiotrat well site details or Well
'w .abandounieut details,-You may also attach additional pages if necesility_
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CONSTRUCTION.DETAILS OF WELUS)BEING ABANDONED - suntrrrAr,INSTRUCTIONS •
.4.INO wilt rop.itrn.cliatA tecui7e1(m'II aviddok. Foi•inathigle injecnnig or.i•iu-or.ur.r.sy-pply •
meikOhil;ir untt the sakite,eonsnoerion'obolulnUenan.p.m eau$ubmit An 1 e fifeiti- ' Nati:.For All•WettS: Sub nit this from Within,30 days of completion ef Well
,abtiodotinient lb the folloWitig: ' .
6a:Well 1114:PDI-°B.-1
Dhision of Water Rmay rem,•InfonnationiFrocm.sing Unit,
61.Ted well depth: •
• (ft.) 1.617-Mail Scivice e6itet,Raleigh,NC 276994617
77 . .
IOU.For linleciloo Wells:-in addition to sending the foul'to.the address in iga
.above,also subniit one Copy of this fornt within'30-days of completion of well
. 6c,Borehole diameter:1 094 abandounient tothefollowing: ,
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Division of Water Resources,Underground Injection Control Program,
. . 6d.Water level lid oun o*grd surface:.12 (ft.) 104 Mail Service Center,Raleigh,NC 27.659-1636
10c.For Water:Sum:Iv Si Infection Wells: In addition'to sending the form to .
6e.Outer easing-length(if linnwo): (ft) the address(es) above. also submit One copy of this four within 311 days of
completion of Well abandonment tO the-county health department of the county
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Of.inner easing/tubing tenth(if latown) 67 (ft.) where indoned,
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6g.Screen-length(If known):1° (ft.) I i
RIM GW-30 North Cacollm Department of Environment and-Natural Resources-Division of Water Resources Revised August 2013