Cleveland_Well Abandonment_20231101 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Chm s C ree n ei 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,onl 1 GW-30 is needed. Indicate TOTAL NUMBER of
3 5 A wells abandoned: one,
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): .(gal.)
-A E F I�e I LJRI 1 r1 im £ P((m SC(' 9* e T-w—, FOR WATER SUPPLY WELLS
/ONLY:
. ^p Company Name J 7c.Type of disinfectant used: f lih Ior�'Ili
2.Well'Construction Permit#: I 1 1 573
List all applicable well construction permits(i.e.UIC County,State, Variance,etc)ifknown O
7d.Amount of disinfectant used: l(JW
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check"all that apply):
❑Agricultural ❑1�Iunicipal/Public' ❑ Neat Cement Grout. ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Coolin Supply) Residential Water Supply(single) ❑ Sand Cement Gro '� ' ' 04D�'• Clay
( S/ g PP Y) PP Y( g ) �_"1,.-;- , F .1 rY Y
❑Industrial/Commercial ❑Residential Water Supply(shared) Concrete Grout NOV
J I n ❑ Dnll Cuttings
❑Irri ation ❑ Specialty Grout 1Y 2l'2� El Gravel
Non-Water Supply Well: ❑ Bentonite Other(explain under 7g)
.; �
❑Monitoring ❑Recovery M�t-S;c�'�.^ r �S
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge El Groundwater Remediation [ j ���.� ��
❑Aquifer Storage and Recovery Salinity Barrier ` 1 i
❑Aquifer Test ❑StormwaterDrainage
i
❑Experimental Technology ❑Subsidence Control tJJ
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a.brief description of!the abandonment procedure:
�
t
❑Geothermal(Heating/Cooling Return) El Other(explain under 7g) �- dh /II irt
7' ' S'
4.Date well(s)abandoned: 10- 1 8_ a0@3 w;
Sa:Well7ocation: -- — - -
c�n I I I
Facility/Owner Na Facility ID#(if applicable) 8.Certification:
2313. S awe,*e Sf-. She16 i . 10-1 23
Physical Address,City,and Zip J
�j Signature of Certified Well Contractor or Well Owner Date
`-'(P @O By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 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:
(ifwell 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 I
SUBMITTAL INSTRUCTIONS
Attach well construction record(v)ifavaila6le.For multiple injection or non-water supply wells i
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: I (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.)
above, also submit one copy of thiis'form within 30 days of completion of well
I i
abandonment to the following:
6d.Water level below ground surface: ^� (ft.) —Division-of Water Resources Underground-Injection-eontrol-Programi-- — =
1636 Mail Service(!enter,Raleigh,NC 27699-1636
1
6e.Outer casing length(if known): - (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): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016