Cleveland_Well Abandonment_20231101

_WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Antractor Information: WELL ABANDONMENT DETAILS
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I�ilS &r(QQ,nQ) 7a.For Geoprobe/APT or ClosedLoop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GWi 30 is needed. Indicate TOTAL NUMBER of
135Awells abandoned: ()r) I ,
NC Well Contractor Certification Number 7b.Approximate volume of waterrremaining in well(s):A2 (gal.)
�elI C r� r FOR WATER SUPPLY WELLS ONLY: .
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Com an Name �� :•� � T 7c.Type of disinfectant used:.
2.Well Construction Permit
List all applicable well construction pennits(i.e.UIC,County.State, Variance,etc.)ifknown
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 rout-T Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) q6esidential Water Supply(single) ❑ Sand Cement Grout ' 'Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) V Concrete Grout N O V J 1 2023 ❑ Drill Cuttings
❑]rri ation ❑ Specialty Grout i ❑ Gravel
Non-Water Supply Well: ❑Bentonite Murry � -El',-Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation �''
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❑Aquifer Storage and Recovery ❑Salinity Barrier Fill drrt - cn
❑Aquifer Test ❑StormwaterDrainage �nnl'r u
❑Experimental Technology []Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ►�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 1 w�—
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4.Date well(s)abandoned: 10 ' IQ � IV�3 �f
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5a.Well:location:
J 7-71 s woweP�
Facility/Owner Name 9F.cilitly ID#(ifapplicable) 8.Certification:
1(o4n E DIXon _� ; �o-
PhysiA Address,City,and Zi Signature of Cortiftcd Well Contractor or Well Owner Date
- 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:
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 weltconctructionrecord(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#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
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6c.Borehole diameter:�-7 (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): V V./ (ft.) 10c.For Water Sunuly&Iniection 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): -6—
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016