Guilford_Well Abandonment_20220818

NVELI _ABANDONMENT RECORD Far lrrietrtal U.4;ONLY:
This fohn can be used foe sjggk or mtdtipte wells
1.Well Coatraelor Information: LL ARANDONMENT DFTAILS
i
Brian Ewing 7m Number of hells being;abandoned: 1
11d[ oeteremrName for%ill.oes,oer persanallyAunlaning well bn hL011er pmpcnY) Ar frefdople 11yeertcor or znsrr In fee sgpfv, wrelts ONLY will, Mw z&jje
c=cwa rrnrtervaur amA rrtienr,bran ezurakl)t uwa faun.
4240-B
NGArcII Conirxc9orCEnifat1iaaTfinnber 7b.Appntlximate volume(if wattTivin:uning in well(a)t 1)
SAEDACCO Inc FOR WATER SUPPLY WELLS,ONLY:
CltnipanyName 7c type of disinfectant used.
,p ,
2.Well Constmetion Permit d
LMdfl Jkr.V!<h rvrflEr MAV(le-C4MMN,,mAe,k'aHwx-e.hymiaiir ekJ tfAm)wn 7t1.At114ttnt of disinfectant tlSrll:
3.Well use(check—wcU use):
Water Supph•Well: 7e<Sealing rnaiterials geed(Chock all that apply):
qA aictaltttrtl phlrtnis ilrftl/Publi' 0 Ncat Ccrucnt:Grout N Rcatonite Chips of fellers
❑kothcmml tflearingOCooling Supply) ❑llcsidential Water Supply(single) ❑Sand Ctnterit Gioul ❑Dry t I v
❑indinitriAlCgIDnren:ial ❑Residential Water Supply(shared) ❑Concrete Gtotil. ❑ Drdl Cttctings
❑ltr ation 0 Specialty Grow ❑ Gravel
Non.Watc;St3ltpty Well, - ❑ Bentotute SlurU ® Other(ex;plain under 7g)
limonitodire ❑Recovery,
Tnjc+dtiimtn Welt• 7f.For each material selected above+pr Ade attmurnt or niataials used:
❑Aquife:r Rccharge NGtaundwiter Retnediation
0Aqui et Storage anld Fteeor,erey ❑Siflinily Border
�AquifeeTea ❑SioralwaterDrAitinge Bentonite.:1501b ,Wtr:gal.
❑Eapetimenlpl Technolok ❑Subsidence Control 7g..Provide a brief iescript nn of the abandemment ptoccilurc:
Mvothenaal(Ckised Loop) OTfacer
Removed DPT Tooling and abandoned boring with hydrated
®Geotbertral t�eati Uf Conlin ItC[UCtt} ®Qtllef(� lafu under Z )
bentonite chips.
#.Datcn't11(x).Ahandoncrl:
06/25/2022 It �--
Sa.Well lrteation: A.1)� 1 202-
Former Cotton Mill Square Site O�1 fOt kF Unl"
rtrtlliiyrX*rterNv= r oilhy 11}5 E pplicablc} s.Certification:
p%,VQr�6OG
801 Merritt Drive Greensboro, NC 27407 Brian EWi n 8/10/2022
Physical Address.City,sad Zip ,P tht .-,ti Chvty Dale
Guilford 13y xiRrft.thivlarm, 1 henehv certr;,(" that the wellfs)wax 6rer+e),ahtwdoned hr
Cautaiy Nivii Wntttieidmi No.(PIN) aitzxnrletirtz iuith 15.4 XC4C 02t";010 ur 2C,020P &4ttt:6'ds
oral tlrof a czapa�afftris record hm bear protvded to tare well owner,
Sb.,I..atitode and longitude in decimal degrees.
ttrxi tt trt1t1,cute Ltr huts "lficieVA) 9,Site diagram of additional well, details:
You may use the back of'&s page to provide additional well site details or Hell
N W abandonutent details. You may also,Vlach mdditionaf pages if rrectssat%.
CONSTRlICs'I`MCDl TAILS OF 1 LIAS)IMING ABAMONED SU 1MIMAi.INSTRUC.TTONS.
.lttrxy4 act1 evmvlructfrire rCctirif(57 (ava7keCk! Fran mLhy�tr ilr}Eeririre:r�t f�n�iuuur su�rh,
Ne1LcOd1tLYtrtfAtlusmurrcr»nrtnueerinn`apoixfruvrrt��t. anvhamsirlrmtilure lGmrr_ Iffa, 'For All %Veils: :Subinh this fmn within 30 days of completion of urll
62.Well ID#.CAT-40 abandonmcal to the following:
Divhimr of Water Rt ourm,Information l?rPtessiug Unit,
6b.Total well depth: 77 (ft,) 11 1T Cca Awl ter,Raleigh,NC 276994617
10bb.Fnr :r lerltdtt W e ls: In addition to sending die forni to the add tiess in 10a
6c.Borehole diameter 6 fin.) eve.also subodl one bopy of this fbink teidiia 30 days of completion of te�e11
abaridonmem to the following:
fid Water lcsd hclmt ground surface: DiAlsion of WakTResoufees,Underground Injection Conlrol Program,
1636 Mail Scr%icc,eatir,Raleigh,NC 27699-1636
Ge nutcr easing length(if known): (ft) lire. Ear Water&I!Rjr aF Ioiectiatn Wc11x: In addition to sending The forth to
the addresses) above. also subMit one copy of this form Avri8tia .10 days of
completion of well ahsnclumnent to the county health department of the county
«firrc abandoned.
6f.lnnet•casini„t'Mbing tt�ttgth Cif known): (ft.)
6g.Streets length(if known): (ft.)
Form G11'-�0 NortlrCarolim Depanvicit ofEnvironrncm and N:uurzt Resources-Divislon of Water.Rctotures Revised Arrpst4013

E
N ELL,ARANDONAIE'w1T RECORD FOTIrIcrkil Use t .Y:
This form can be used for single or multiple sells G
1.Well Contractor Inforanatitrn: WELL ARANQ!QNT*1ENT DETAILS
Brian Ewing 7a.Number of trells being abandotled: 1
WeIrCounciorNmik(or%Uouza pusarisily ihandatting well on hWherprapes v) For midapte f!Notor ar mowi6fer svtgrtr wells ONLY with t.Prr sw.je
c!rrr(mcffret AT4amhurmerft,,frjn cwr azudvfUt?fae fnrnr,
4290-8 7b.Appttrximate volume of water'teinaininfi (gat)
Nf Wetl CbrnmuarGe~nif�Ii,an MmrtbCr j
SAEDACCO Inc FUR'WATER SUPPLY'%%TELLS ON''1[,Y:Quipany`Naas 7e.Type of disinfectant userL
2.Well Constmction Perrnit#
Litt ale o,tj tErnbh.well p rmAy ri e.Caar nAl Swe.kbrlafty,bble fort:&0rkiwwo 7d.Amount-of disi fectiint used:
3.Wetl use(clrccicWell Use)—
Water Supply Well; 7e.Sealing riratcr ale used Ohm],All that al►plr-)s
bAgricuitrtrat blvitlnicipal/Pdbli • 0 Nett Cement GroCrt (R 13erdophd Chips or Pellets
❑Ceolhcnivil(14catinreCool ng Supply) ❑Pcsidcntial Water Stippl-(single) ❑Sand C6nkpl afatit ❑Dry Cky
❑Industrial/(:ommcF6al ❑ltc%idcntial►Pater Supply(shared) ❑CQncrelff GMI ❑brill Ctitisin
t7trti dots ❑ Specialty Grow ❑Gravel
Non-Wakr Suppt'Well; - 0 Benton➢te 5luety ❑Ot-kF(exTialn under 7p)
❑hl6atiibrLte , ❑Itcco"ely
Irrjcoipn Welt: X For each material selected above,protride amount oUntatelrials used:
❑Agutftr Rechar�� ®Ciroundrtuter•Retattliation
❑Aguder Slontge and Recur try= b9alinity®9rrier
❑AgniftirTest OSiortinl'aterEtrairiage Bentonite. :150lb ,Wtr:gal.
❑Experimental Technology OSubsideikc t&stol 7g Provide a brief ascription of the abandriument procedure:
[3Geotberntal(Closed t,00p) 0710cer
Removed DPT Tooling and abandoned boring with hydrated
®GeothermalO4Wti +CcMoli Return) ®()ther(explain under,7 )
bentonite chips. ap
4.DatesWl(s).ahandoncd. 06/25/2022 �"�^ ° —
5&Well location: AUG 1 8 NIL
Former Cotton Mill Square Site 1ff�i fiY�`tf`r tr^ ' ' UM
FaeilfiyfiDn•r&Name Ficilhy 11"(1tappli'_ble) S.Certification: ��:3130Cs
801 Merritt Drive Greensboro, NC 27407 Briar E1Ali n: 8/10/2022
Physical Addrem.City o
,and Zip S'goglm f Ced tliti Well Cpvta'4l(rf yr-,'Al Outme bible
Guilford 13�-'signing this,/arrai, 3 hereby cerfo that the wel/fs)wus(were)ahtumbned tat
Coataiw Pared ldcrttit iimtNo.(PIN) tattv)Mtt hee Tuttle f 5, XCAC Ok,!i/(Jir or2C.t1.2011`r Il (lttstrilc on.5Y7iwkrrds
and Nrirl a copy crf d/ris record haav a ia?prrnvekat to tyre well owoM
Sh Latitude and longitude in rlcgrcrx/minutcQ/SCt nrls or dcciirt it degrees.
(if*ell-fteltl,otic LtrAme 4S.Wri:itr4) 9.Site diagram or additional null deta[Ls:
You pay use liie baf3 of this page to provide addigonal well site details or mall
P� ►► abandoatnent details. You rua} also idtar h ndtiitiottaC pages i1 necessary.
CONSTRUCTION JWTAIIS OF WELU91i]R INC ARANbONED SURN"TTAL EVSTRUC.TIONS
:ffilrattr„rtl tritirlJ'atxtt4ler ra�urtl(.tJ ii rn%afl�lr Frir lirulfiph frry'ri:rl+iir iir n�n•itwfav'.rer�h
u ellsONtr ti;M rife aunty-axifctrrfeefirmrrrhan[ta5r�enG_trkt call arena wWfi-trm 10a• For All t 4Ak Submit Ibis fwm %iithin 30 days of completion of .%r l
62.Well[DpI4CAT-41
abandonment to the folluxOng.
Division of Urater Rfty'�urces,111ro niation Prorftsing Unit,
1617 Alail Sici%rice C ntcr;Ralrr�,NC 276"-1617
fib.Totat we l depth: 77 (ft:)
I Ob.F°or I ec1Jott.Weals: In addition to sending the form to the address in IOa
6c L3oxrhole diameter.6 (yn,) above,also sttbritit.otte_,boM of dais Bonn uithin 30 days of completion of a*ll
abandonitt io to the Mowing:
6d Water lcs'c1 hClr graRntl m'fase' [ft) Di is%nof Water Resources.'Underbrouod hijeaton Control Program.
t636 lliail Scr%icc Carter,kaicirh,XC 21(M4636
e�aorr M.tbmeh-,olstb Lion Wells: in addition to sending the forth to
6e Outer casing Icn h(if hnmrn): tree) ( t one:cM, of this foent uritbin 10 days of
completion of well abandonn ent to the county health department of the county
where abandoned,
6f.Innercasina:/titlrin)!length Cf hnutitn): (fL)
6F,Sereen length(if know). (ft)
Form G1V-30 North Carollm Depanarix of Emyronotent and Natural Resau ces-Divisfan or Water Wsoarccs Revised AuLusl:WO.