Cleveland_Well Abandonment_20230818

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
GregBoggs 99 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
4514-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
SW E, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
EDAgricultural
Supply Well: 7e.Sealing materials used(check all that apply):
❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
hermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
strial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout a Drill Cuttings
ation ❑ Specialty Grout ❑Gravel -
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f,For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1 Bag Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Soil Cuttings located onsite.
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Dug out well casing to approximately 12"below ground surface.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Filled well with 1 bag of bentonite to 12"from top of well.
4.Date well(s)abandoned: 7/31/2023 Covered bentonite with soil cuttings from drilling.
5a.Well location: '
Neisler Brothers, Inc. } t " - s �'
Facility/Owner Name Facility ID#(if applicable) 8.Certifre r n: A U G 'A 8 2023
York Road, Kings Mountain, NC - I 7/31/2023
Physical Address,City,and Zip Signature ofCertifi d ell Contractor or Well OwnDWQ11306 to
Cleveland 3503380246 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.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.209779 N -81.339232 `,1, 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 - -
Aitachwellconsiructionrecord(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#: TM W-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6.28 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Infection 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
6E Inner casing/tubing length(if known): (ft,) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016