Cleveland_Well Abandonment_20241001 (2)

WELL ABANDONMENT RECORD ForttmrnlalUseONLY
This form can be used for single or multiple wells
1.Wen Costrador Informstiara: WELL ABANDONMENT DETAILS
Brian Ewing 7a.Number of wells benig ahanduned: 7
Well('ntrracson None tat%%ell uNlrr pereotulh alvnhnung%+rll,ut Ith Ixf ptopem I V v mulnpk atlecrwm ,M' IMN!-M(N<'Y .ulph weNs ONLY with Ilrc• .,,mr
,,.mnarn.Nll,J.elh.hwlnn•,N.n.v .N.arovlwn rr.,•lr,
4240-B
NC Well Commdnr<cnific;du+n Nnntur
71).Apli m innate srdnme of wale•remaining in helps): (gall
SAEDACCO FOR W ATFR SUPPLY W'FI.1 c ONLY:
Convaiis Name ?c.1%pe of disinfectant u%ed:
2.WeN C•ratttrction Perak ill-, , W10300529
l�srullynptarrM14 uer!ltvmdrn.e.i wM.Sluk.larnurce Lce.hrrv.rn !Alai„
?J, Amount of disinfcctanl u+a•J:
J.Well use(shed:well use):
Water Supl►l}Well: 7e.Sealing materials used(check all that appn):
❑Apnculnnral ❑ManclpaITublic 17 Ncat Ccrocnt Groot ® Acrronnc Chips or Pellets
06cothcmal(HcatnntK'ooling supfAl l ❑Rcstdcnttal Water Supph isingle) ❑ Sand('eineea Grout ❑ Dn(lay
❑hdusnnal:Comnicicial ❑Rcsicicntial WaterStipph Islaitd) ❑Concrete Grout ❑ DrillCutlitip
❑Irn••liuu ❑ Spectalh Grout ❑Gra%el
Noe-Water Supply Well: U Benlomte Slum 1.1 Other(explain under 7g)
❑Manuonng ❑Rcco%cn
Injection Well: ?r For each material w4cmd aho%e,prinidr amount of materials used:
❑Aquder Recharge ❑Gromdncuer Reniedudion
❑Aquifer Storage aid Rccotcn ❑Salmon Bauer
Bentonite.:501b ,Wtr:gal.
❑Aqudcr Pest DSlone»%alrt Urnnage --
❑Expicrnterual Technology ❑Subsick cc C'ontrul 7:;.Pro%ide a brief dimeriptinn of the Abandonment procedure:
OGeolllennal(Closed Loopi LITracer
OGeothemal(Rennin +Conlin RetuReturn) Ibfhtice tcs lam und,-t? I HYDRAULICLY PUSHED SENTONITE- --
4.Date ae"(%,abandoned: 8-29-24 +—
ia.�1rll bcation: '024
Downtown 66 Ilrs`-;�:.i 4.c.- ; r3-r••yipyjl,r 1
$.Cerdfk Ww;
Fa..i�. i, .� �.inr Pxilih IDM(if applicabk) r•:.-.,
232 E. Marion St. Shelby, NC 28150 _Brian Ewing 9/12/2024
Ph.steal Addrres.0I.N.aid Zip Sign sum of Ccnilied Well('nrnracenr,:.v-110itrs¢r Dare
Cleveland lit .ugning dies Am-m. I hereby cernby dhm the well(s) was(were% ahrn,Mned in
t,,I]Al I'u.d Ides"ratum No.MINI acconlaru-e weds 15A.'vCAC Or.0100 or;C 0200 Well C'onstrucnno.Vanilardt
and►haw a cvM,oJtkis record Aim bean lxnrxkd eo the well oirner.
511).latitude and htngitudc in dcgrervininutrv%irconds ordeeiwal degRtes:
„ f rt id ,�'I:n t:•li L.nnk>htl 9.Site diagram or additional wall details:
You oia% ter the back of this page to prof de additional cell site details or%sell
N R Abatdoontera details You mta% also a11ach additional pages if m ccssan
CONSTRUCTION DETAIL 1 OF WELLISI BEING ABANDONED SL'•BMITTAI.INSTRUMONS
:Irtrxh will cr�arirualalre mcrual s+{!o(whtlrh. hw multiple intiection rw mn-uauer mpplr -
welkONLY with fhe clone awr+oehe lam sh NuAr r,Nent-i..N cur whmll Une Nunn 10a. For All W'cib: Suhnut this firm eithm 10 da)s of completion of well
6a.Wen ID#:A-2-14(EVENS) abandonment In the follnu Ing
Minion of WaterRe next r%.Inlormation Processing Unit.
6b.Total well depth: 21 ((t,) 1617 Mail Smice Ccatcr.Raleigh,SC 27699-161'
10b.For Inkcdan Wens: hl addilual lu setduig,elk form al Ilk addtcss ut 103
2.25 abuse-also submit one cup\ of this(onn wilhin W days of cuniplcnioo of%tell
tic,Borehole diameler: On.► abandoontera to the followurg
11106isiom of W alrr Rtmeurces,Undergtsiattd Injection Control hagram.
fill.Water ktel hrinw Lwounil%urface: Al 1636!Hail Smice Center,Raleigh.N('27699-16J6
10c. For water Supoh dt luil cthim Wells: In addition to seeding the form to
6c.Outer casing length lifknownl: lhl the addressiesi abuse. also submit ooe copy of this form t%ithin 10 dms of
completiun of%Nell abandaninem to the counh licabh t1cpannicn of(he count.%
6(.Inner essing,+tabinL'length(if kamw n lrerc abandonednl: (fi.l
fig.Screen length(if hnoAn1: (ft.l
FotmGW-10 Non ('arolim lkpannrra of Emnonnient mid Nowal Nesatwts-D6isionof WawrRcLouims Re%ised Aopau 201z