Cleveland_Well Abandonment_20240311 (3)

WELL ABANDONMENT RECORD For Imemd UW ONLY;
This fonn can be used for single or multiple i8tils
1,Wett Contractor lnformation: )YELL ADANDONMENT DETAII_9
Stefan Smith %Number af%llsbcingalrandanl l 1
l%,Q3i, odmctorNaurc(or urllnueLYNmonaily atumidnin; R1&'kr Peas" Fa' Inirhlplc lnfec'Hwe or rain-n•nler supply wells ONLY with 11,r same
CorlshfrtfJq'1�'irhOlnhNrNj�7lt,jvn clot 5'nUfhA YNIaJF�rr1L
3576-A
1�c11 Conirador illfiu�tioii lYnni+cr
7b.Approithuate ynlume of;bate'remainhig in ivcll(s)i
TIC (hai•)
sAEDAcco 60R WAU R SUPPLY WELLS ONLY:
Coa>Qan}Name 7c.Type of disiinfectaut used:
2.Welt-Coustruedoit Permit 4:
list rill lr f,11hVbk-twil prmitr{i.a:Curnn',Srma,l'uriarwe.liDIAl nn,,do orkmwn 7d Amount of dISinFCttsint U3e41' '
3.%VclI use(check well ux):
Water Supply Well: 7c,Scaling mitcrials used(cheek all alit Apply): .
❑Agrictdtural E.3NhMicipallpltblic W Neat Ccrucn(.Grout i ❑scotonitc o- orPcllcts
RGcolhcrmat ftidnrJC.00liuoSupply) . 13Rcsidermal 1Votcr Supply(rdnglcJ ❑Sand Cent nt Gniur �, ❑Dry CIry
❑IndusidalfComntcici II ❑Residential%Vatcr Supply:(sharod) ❑CoucieteGrout O Drill Cutdul s
❑Irci lion ❑$pecuiltyGrout. ❑Grutiel
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Nctn-WaterSuppty Well.- Cl BctnouiteSluay I ❑Other(esplain under 7g)
I munitodne. ❑Ltcc:oven,
Injection NVC11, X For each tuaterial selected above,prot'ide amount oNtatesials nkd:
❑ uiferRcch:u*e ❑Griiundaaler.Reinledianion
A9 Neat-Cem.:47lb ,Wtr:4gal.i Sand Cem.:lb ,Wtr:gal.
OActui&r Storage and A&x%'eq• ❑S linty Dardcr
❑AquiterTest ❑Sibrun ater©phuige
Sentonite.:llb.,Wtr:gal. l
❑Espetintenml Techuotoe_v ❑Subsidence Couitul ?g,Pettoidea brief descripdaa of the ahandnnmeat procedurm
❑Geothenuat(Closed Loop) . ❑Tracer I - - -
Mixed drum of grout (3751b Portland cement 51b bentonite,
®Geathemtal(fit�nGrtlaiCoolin Retum) ❑Othci't� lain under 7#t)
powder and 28 gal water) then tremie grouted wells_.
d.Dato acll(s).abandtincel:2-26-2024 j
Sa.Wc11 Incation: I,: �-i: L Lo:
White Tire Center q R 1 7 /�ryA
Caciiity/CMrxr'Name faomy tDii(ifapplicabic) S•Cel9iRc etioit: I t 2014
/( Irlt`t7i7i4£71�r
2715 Fallston Rd. Lawndale, NC 28090
Physical Addic"s,City,and Zip S ilnrc f Ccuir,svl Wctl Conn r tnror Well Un'rtr ' = uaic
Cleveland Ry sigirlrig this form;7 her�hy certify dual the well(s)was(Ivem)ahlvidoned in
Comity Paivel ldsalficitbnNo.(PINj riccvn7{riicc tvillr 15 t:1G[C 02C.UldO:ar 2CA2aO tt'e1!'GviislrrlctiU7J Sl(rrf!&rnls
and Aral a copy ofllris re cnJYl hers bE r provider!to lire ri'c11 onven
5b,l ltinrdc and longitude in ttcgmslntiuutcslsceonds or dcchnoUdcgrcq.
(ifacu 11504,one Wlota irsti07cictsl) 9.Site tliagrani.oi-add(don►al well dceats:
35.474260 81.510389 You-ltat5'use die back of this.page to-jtroF'idti additional ittlt site details or Well
N . NV abaudoinnettt details. You tua}also vtaclt atlditio►r1l paw s if tkcassaq'.
CONSTRUCTION DETAILS flit WEWS)BEING ADANIDONED SUBMITTAL tNSTRLTCTIQYS
:Brach u.ell cprislr'aCllun avcordrsi if available. Fair irrultipfe ii jegiyn'ru•rain-u'nii'r supply r
u-ells ONLY i0di rhn mmlq cwc+irtaclmir•'izhanwili,'urn.i un can subaiii cvre tunic. llla: For All Welk Submit 11ki fonn ninon 30 days:of completion of urll
6a.Well ID •MH'-6 ibandoumcitt to tW l"olloi ikR:
DiAAdn of Water Rcsour¢rs,Iaformation Processing IInit,
61►.Total tt'cll depth:
20 1617 Mail,SeMce Ccatcri Ralc(-h,NC,27699-1617
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10b.F-hr Inlccliort Wells: In addition to Sending die fornt to the addresi iu 10a
6c.Borehole diautctcr;2 (iu.) abm,.also submit and cope of Iltis,fonn n'ithiii 30 days of compterion of n'ell
•,Ib4ndountent to the foliow,ing:
D)Ivislottof Wulerlicsourees,Underground hijecttou.Control Prdgrami
6d.Water tCVd bctou ground Surface-'12 (ftJ 163E Mail Service Center,Raleigh,NC 27699-1636
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6aOutercasingIcn;,th(iflatntire): (t't:) 10c,rinr Water.�i nit &Tgj ction Welly; In addition to.scndiog the fomt to
the address(es) above. also submit lotie cap)• of this farm within 30 days of
comptction of irA abandorunent tolthe county health depannterd of the couch,
6f.Inner casini„ltnbing tcnjKh(if[arna'n); (ft.)
wherc abandoned.
6g.Screen length(if Mmiu):
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So mi Gl1r-30 Revocd Augus3 2013
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TELL ABANDONMENT RECORD FarlmerrrdUsaONLY;
Tbis-foim can be used for single or multiple it-ells I j
1.,Welt Contractor Inforination: W.LL ABANDONMENT DETAW
Stefan Smith 7a �IumhcrofwcilsUeiny�abundU IcrG: 8
Welfcor/caelor Name(or w&lowa .erp(upeny) For wi.rtaple, h reelfae cw rmra-trtiteay srrPpfp welb OWLY setdr .11m. some
c�rrsfmrrcrluvum5mnhamiructaf,ie,mcaaeselu,rl`rwi,k,rnr;
3576-A
1JC Wc11,CoaitaclorCanifraiion Nnnt6et ?b.Appmifinste volume cif ttatm,fiimainitifi in Well(ti): (i;+tl•1
SAEDACCO FOR VVATFR SUPPLV WELLS ONLV:
Gonrpany Narnc' %Type of di.Wnfiwtaut urcd:
2.Nett Consttuctlan Permit -
Lfd tell1gyVi4vide a-ellpuvmidt(Le.CumV,Soak,d'urJa me.Irrjvdinrr„c+lc:,y ffdsmwo 7d.AmUttntUf tll5lnfeCtslnt ttSetl•
3.Well use(Check Wen use):
FV:tter Supply Well; 7c.Scaling matedils usc+l(citcct;ail that apply): .
MA0,piltUtal pMunicipalrPubfic• DI'Neat•Cement.Grow ®Rcranitc Chips orPeiicts
C3(cotitcnntl(HciCiiki'Cooling Suppl),) 1712csidetttial Water Supply(single) O Saru1 Ccntent Gmut [�qty CL►y .
❑hutoslriailCornnrcrcial ❑Rcsidenti,•dWatcrSupp4,(s}wrrd). E3 C611ctetdGrout- ❑DtillCuttiug$
Olni lion q Specialty Grout 0 Gravel
Nog-Water Supply Well: 0 Bentotnte Slucrf )0 01her(expiainpndet'7g
�hloriitoring. ❑Recovely
laicction Wcth 7f,For cash tualelial selacted abov,provide autoulit 6f.tttaterials need:
OAgniferRCc[targe. OGruundwaleildcmediation Neat-Cem.:471b ,Wtr:4gal.' Sand Cem.:lb ,Wtr:gal.
OAgnifer-Storage arxi R��c(n'ery [7SaIndh+Barrier
Bentonite.:llb Wtr:gal.
❑AiptiferTest" OStonmvaterDrainwe
Ot\periutenlal Technology OSttbsidetrce Coniml 7g.Pratide a brief d6criptian of the A ndnnmeat pcnwcdure:
OGeolhennal(Closed Loop) riTracer
Mixed drum of grout (3751b Portland cement 51b bentonite
©Geothenttat(H1.ntinttlCoalit►RRelum} .- ®Othert� Iainunder7lt}
powder and 28-gal water) ithen tremie grouted wells.
4.Date WCll(s),abando,lwi:2-26-2024 T a
_ rt._i
8a.WAtncation:
VrLd
White Tire Center MAN 1 1 20Z4
i'sciiity/thvn:rNacm: raalitylDaCfapplicabic) $:Cei'liticntioil
tn�c rya;t?r •-r�
,,:•�»:.
2715 Fallston Rd. Lawndale, NC 28090 _ .��„ �I2'9f2024
Pls}'sisal Address,CiJy'rat�d Zip 5�alnre•:.CCrtiJiCd t4'dl C;itncrraaf Ur WCII thsn:r D;tte
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Cleveland Hy,sigubc,this farm,I hemrby cea•rtJya'hal ldw u'ell(v)was(lcere)ahaurrloned ire
Conniy P=0 Id.wit-te:ifti No.(PIN) anewdWice 1011111.4:1+UAC 42C,(l100,or 2c.02 0 rVell Ccrn;ahicfiun Sflinrkirrls
and drat a mP3•of%leis reca rd hay been provided!o ike troll 61mer.
Sb._I ltihtde;rnd longitude in dcgt'ceslntlntitcs/sccnnrls ordccintal ctcgrccs:
tit�i clt e.5td,orK latlltul;is iJricici t} 9.Site diagram oi addltiottal well dclalls:
You tna}use(lie backof tliis page uiplovide additional tell site detnils.or troll
35.474260 N 81.510389 VV atbaudoornentda(ails..You nta)'also altaelraddi¢i01Nl(xtg s if trecrssan.
('6wrgit(."1'IfIN DrTAIl ti t`1F WELijgl.BEING ABANI ONIED SUB14 rl AL tNMUCTfONS
:t!lrttlr n'eB cwriyh rcirora mirmrda)V'utiuJhlJld. l or,mr!liplr i,feciion'a n�n•uzrtrr sa pf,lj
it-el1,v ONLY trtlhA,Ai7uwrrucstmrnrflao'raM1arthuymgst.iarm Carl s,rbm'llarefiJrm. 10a.Far All Welk• Subttdt.this faro within 30 days:of completion or well
6a.%Vcll ID#XWM B abandonment to the fallowing:
Divislda of WawrResaamoi,fnform:gfon Prucessin{;Unit,
6b.Totalivell deptir. 20 (ft.)
1617 bUil Seititice Center,Raleigh,NC 2.7499-1617
QOb.F-nr.tn leellan Wells:';Ili addition to sending lite forth to Cite addresi in IN
6c.Borehole diameter:2 (ln.) above.also,subndl otic iopy of this'fonn within 30 days of completion of ci+cll
ybandonntent to the follU«•ing: I
641,Water tevcl.betow">trrurid nrrfaccd 12 ( ) Divislotl of Water Resources,011dergruand hiject(ou Canny!Mgratu,
1636 Mail Scruce Cct'ttcr,Raleigh,NC.2i69')-1636
6c.Outer casinglcnolr(irlwown): (Ct:) 10e.'Fnr 1 ter.511 lily A,iuiectio,i IY�IIa�: In addition to.scading the fowl to
the address(es) above. also submiaotie-cop}' of this foltn within 30 days of
completionell of%N nliandaitment to jlhc county irmlilt dcpanntcrtt of the county
6f.InnercaAnWtabiag tength(if I:nat�•n):
where abindancd,
6g.Screen 1Cugth(if htiowtt):_ (fl.)
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Force G%V-30 with Carotin Deponaxm afEnomwenl mrl Nauss Rcsomms-Dhuiav of Water Re;i ILMs Revi ed Aagum 20t3
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