Cleveland_Well Abandonment_20241001

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WELL ABANDONMENT RECORD \� rlakrnaI Use 0INIY
TUs form can be used for single or multiple wells
1.Well Cantractnr Infortrtstion: WELL ABANDONNIFNI DFA A11 S
Brian Ewing Tar Number to(wdls briny;abanthsned: 7
Well Comm"Nance im well tow IWI perAimill}Amnhunui;well oTt his+lier propem r Fw mrloplr atle,wor ,w ,ryr•wnrer st4V6• wells ONLF -ah W uYrrr
..,n via p��,du•edwm.nr n rr au,rrh,ruf„tore hrrm
{2{0-B
NC Well Commctorfcnlfa::dw n NonthcT 'b.App IXIIII tc%oluniC of water reNlAitoias in well(A):
SAFJ ACCO FOR II A'IFR SITPI I NFLI NONLV:
Compea)Narm -t.1%lit•of disinfectant used:
2.Wdl Ceasemcdam Permit C, , Wi0300529
l�sr roll rrppiir it to wel!Iw rmilr n.r.r wnfr..t)rda•,t,rnorcce brier tone.oc rl Aln,w,r
'd. lmount of JisinfcCtanl uxd:
J.Well ux(chetie w eli tone):
Water Supply Well: 7e.Scaling material%u.Cd((heel,all that apply):
❑Agncultural ❑Mrmtupal:Public ❑Ncu Ccmcm Orott 3 Bcnrnnac Chrps or Pcllcts
❑Geothermal(HeatinwCuoling Suppl).) ❑Residertial N'ater Supple Isingic1 ❑Send Cernew Grout ❑ Dn(Ln
❑IdumnaKommcrcial ❑Rcsicicnttal%Vatcr Su)ph I sluircd l ❑Cowmic Grout ❑Drift Cullinp
❑ltri •tiuu ❑Specwln Groan ❑Gra%el
Non-Water Supph Well: ❑BerMonite Slum I I Other(ctplain undet 7.g)
❑Monuotnig ❑Rct:o%cn
IAjettion Well: 7f.For each matrtial wk-tricti alio%t.lmnidr amount of materiah towel:
❑Aqutler Recharge ❑(iromdw:uer Runedimon
❑Aqutler Storage aid Rcco%en ❑Salunn Hamer
,
❑Aquifer lest ❑Stonm Sentonite.:501b Wtr:gal.%;trr Drainage -- -
❑Etperintemal I echnology ❑Subsideme Conirul 7g.Prin I&a brief i1mriptirin of the abandonlrn•nt pro(Cdure:
UGeolhemtal IClosed Loop) L 1Tracer
liGeolhennall lHealinglCooling RelReturn) PllOtfier(ct aim under 7 ) HYDRAULICLY PUSHED BENTONITE_ - _ -- _-----
1.Date it,ell(%)A WNWI d: 6-29-24
Via.N CII location: n r n .
Downtown 66
R.(rtlillt'Alltti: tf. is r.+,.i.f t' f�'.' i+i4 T: tiJSit F+tctlrh lhtricr N;isit' facility IDM(tfapplicabk)
°` � `�"
232 E. Marion St. Shelby, NC 28150 9/12/202{
_Brian Ewing
Ph.stcd Addicts.Cm.aid Zip SryyrWnrc of Cenificd W'eR(bntrxMr:: �::11 Qxrtcr Dore
Cleveland At'signoig this J6rnt, 1 hemby cerh/p Nrtr the well(s!was(were, rastmid m d In
('tows» d Plo kh ma:cTtau No MINI uc't'onhuur with IJA.CAC OX.0100 or X'01W Rill Conmrrurtinn.N(artrAmix
and that a cvp}of/his record has been prm mkd io&e well owner.
Sb.140tude and langittide in tkymrr.rminutCs.(roods or decimal degrees:
(if well field,osa 4tu'lnitg is Nrlfttrcnrl 9.Site diagram or additional well dr;tail.:
You mat use(lie bade of this par:I-t prrr%sde addniotud(tell site details or%tell
N W' abandetimem details. You may alw ante(:aldai(nul pages if mcessan
CONSTRIA TION OFTAILS OF N BEING.ABANDONED SUBMITTAL-INSTRUCTIONS
.likkk will umslnt.)anr rrr,-rd�,+{!01 WI.P11 I'll
rrcu!!!pf.nyrr Durr rr rr,n-w.rla7 sYtyf/' _
w-elleONLYwirhrhr..vmrcwr.tru nrm rti.urrkrmwrnc to, tall wi.mil tow Pew Ilia. Fur All Welb: Suhnut this fortis within 3O dms of compldion of well
GA Ilcll lit=:A-1-13 (ODDS) abandonment in the folloning
Division of Water komerm.Information Processing Unit,
6b.Total wvl*11(1r: 20.25 ffl.l 1617 Mail Srnice Center,Raleigh.NC 276"-1617
100.For Inkrflon Wills: Its atldnwnt lu XidmC fIR font to file address In Ilia
6e.Sorrh le diameter:2.25 abote. also submit one ct� of(Ins fora mthm ;o elms of completion of%%Cll
(in.) abandonment to the following
6d.W atcr k%aI below grnutld wrfacc (ff.l Disislem of Water Retuiurers,I ndcrgmed Inimiflon Coulrul Prnsram,
1636 Mail Smicr Center,Rakish,N('27699-16J6
6c.Outer caminx fill (ry,l Ilk,For Water Sump% A InleetMlN WeNs: In addition to sending the form to
It k l the address(esi abu%c. also tmbivm one cola of this form within to dais of
completion of well abatrfonnsenrr to the cotutN health department of the counh
6f.Inner casinslttohitos Iea;j14 IIf 6rtawrn►: (ft.► where abandoned
6s,Screen length lif I.arowtol: Ih.l
Foam GW-3o Noah C'arohm Dgnrtf era of Eroironmcis and Naiwal Rcsimm cs-Di%isrtn of Wiwi R.wwt.•s Res r"Aupiu 2oII