Cleveland_Well Abandonment_20230905

WELL ABANDONMENT RECORD For Internal Use ONLY: '
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
(G1262-e/o i f`-Q'a-LI.5 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 1 pW 30 is needed. Indicate TOTAL NUMBER,of
7 u /� wells abandoned:
Z1 73 Yf i /7
NC Well Contractor Certification Number // 7b.Approximate volume of water remaining in well(s): ! J C (gal.)
, Fe' .t.c c WeGI�Pc/0v( , FOR WATER SUPPLY WELLS ONLY:
Company Name .
77c.Type of disinfectant usedli Tt 7-4
2:Well Construction Permit#: /�76'49
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.)((known
7d.Amount of disinfectant used: / .C.,a,
3.Well use(check well use): j! -I
Water Supply Well: 7e.Sealing materials used(check all that apply):
DAgricultural 0Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) lit tesidential Water Supply(single) 0 Sand Cement Grout ry Clay
❑Industria!/Connnerciai [Residential Water Supply(shared) ulConcrete Grout 0 Drill Cuttings
['Irrigation 0 Specialty.Grout 0 Gravel
Non-Water Supply Well:
0 Bentonite Slurry ❑Other(explain under 7g)_
- _ ,❑Monitoring: _ - - - '---❑Recovery - - I ; - ., - -
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ©Groundwater Remediation / ee f�11: cif, c/a-A?
•
[Aquifer Storage and Recovery ['Salinity Barrier t� L �✓
DAquiferTest DStormwaterDrainage /3h0 CO*1.Gre....
01;7tperimental Technology ❑Subsidence Control • 7g.Provide a brief description of the abandonment procedure: •
['Geothermal(Closed Loop) ['Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) '7/I lied wi/ �/'t-:.GG l ti-
-
4.Date'welt(s)abandoned: ea 1
5a.Well location: v ` N'w--' ./L..i V L:,L
itCy AIhiei-s-Z . . StP 41 b
1023
Facility OwneiName Facility IDP(if applicable) 8.Certification:
Physical Address,City,and Zip Signatui Certified Well Contractor or Well Owner Date
C;1 eVe-tO-f1GL /231f 1 By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with'SA 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 tat/long is sufficient)
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 additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable,.For multiple injection ornon-watersupply wells
` ONLY with the same construction/abandonment,you can submit one limn,
J ,/ 10a. For MI Wens: Submit this form within 30 days of completion of well
6a.Well ID#: hlit. abandonment to thefollowing:'
I;
Li I Division of Water Resources,Information Processing Unit,
6b.Total well depth: (n,) . 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.Por Injection Wells: In addition to sending the form to the address in 1Oa
6c.Borehole diameter: ` (in.) above, also submit one copy:of this form within 30 days of completion of well
f� 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): 11Z, (R,) 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
6E Inner casing/tubing length(if known): /V f/4 (ft.) abandoned.
6g.Screen length(if known): A/74 (ft.)
Form GW-30 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016