Guilford_Well Abandonment_ (18)

NVELL ABANDONMENT RECORD For lrgcrwl Usc OnY-l'
This form can be used fbr Single or mul0k mtug
1.Well 6niractnrInformation: )YELL ABANDONMENT DETAM
Brian Ewing 7a.Number of wds being abaudo!4
Weil C,�dmcfof Harx(wAlettowney Kesonanyabandarbg Ate on Wjinpi"s,) For "ndtipte ffywrw. or , sqpph, brelts 0AILY with lite mie,
,i1wjefolm,
4240-B
14CWetl 7b.ApInUxinkate volutfiL of water rem eming in well(ip.
SAEDACCO Inc FOR WATER StMPLVIsITLIS ONLY:
C4)TVHMY Name 7r.T�Ve or dinintectinit ulech
2 Neil Construction Pcm1t4,,
Litt$I 4qiAmkA-401wrxity rj.,_t C.Gww Swk,Phriargee.14Minf?eft-I ork... 7d.Amarm I of disinfectant used:
3.W01 u-se tche&*01 usel:
Water I Supply Wdl: lv�Scaling material'used(06'k 411 that appk
b ftrku Ncat CmicnA•Own tj 13cotonite Chips or Pellets'
tlGhv thcrnot Supply) Okcm(knrial%Vvcr Sijpp4,(&;iTkq1q) 0 Stad Centem Grout 13 Dry CVdV
owultrwIlCommCF611 [jRsidedial%Valcr SIpph,,(shw,4) 13'Conmet Guiul [3 Dtill Ckritinags
0 Specialty Groul 13 GMvel
0 Uhler(explain under 7j)
ftF Supp 0 Bentonite Slurq
13MOMItOdhJ2 , oRecowly
injection Weft: 7f.For each material Selected above,pmmidc amount of,materials used-
DAq Recharge, 29Gk6W%vwer ReutWiation
OAquife,Slob and Remvy b$alinity-l3ahieF
Bentonite. :150lb Wtr:gal.
omIllifet Teo 13S16MAA1Atet 03ailiage
oExpefintemai Techaotokm oSubs1denceCbntM Proinide a Initfileictiption of the ahAndonment prpoNfure.
ffGeothennal(Cksed Loop) Mracer
Meothennal(HeatinES2L]iM Return} C3011her(explain under Zg) Removed DPT Tooling and abandoned boring with hydrated
bentonite chips.
F
4.Ditw%vg(s)abontinned: 06/25/2022
5a.Wen hication:
Former Cotton Hill Square Site
OG
801 Merritt Drive Greensboro, NC 27407 Brian I In 8/10/2022
Physical'Adtims.City.wid Zip 11(41-Ir416f "411 Chwer Dw
W e 1(_10 fl 1 r")
Guilford By visaing thisfaml. I hereby Cej1iA,,1hLat the welffiv)was(werg)ahtvjdoyxd hr
Pawl ldeoiMi"04o.(PIN) 6t vnlqn w utflh I 5A X'CA C,621C.01 010v 0-2CA209 Well�Qbkftletioh Stot&wds
and that a copy aftKis remrd Imu hgoo prmided to dre well tywner.
5b.Ladiude and Ionotude in degrees lininutestseennd sordixima 1,degrem
(i wol n6w,ow uttnaea) 9.Site di.-Vam or additional well dc-taffs:
You may use Ile back-bf this page'to provide addifional well site details or well
—W abandoinftew dimil[s. You rua-y' aitaCh a1ditionatpages it necessary.
("owrimeriogg nmnsi]f WELL(t)BEING ABANDONED SMtITTAL JNSTRUCTIONS
Amzek foWl ctimvinwmift fvrx4,d(*)
111a, For All Welly: Subinit 113LS ATM witbin 30 &Ws of completion of well
6a.Weil® :CAT-10 mWnd6ntmcn1 to iie-foilowukg:
Division of Water Resumes,Infortution PrOetwing Unit,
mv Ala"ice Ginter;Raleiffi,NC 276"-1617
6b.Total well depth:.8 7 013
10b.Fbi higglim Wells: In addition to sending dw'fonu-to the addresi.in, IN
6c,florc m
hole djaeit.r,6 above.also submit one bopy of thi 1 8 form
ni widibi 30'4,s of comptttion of mil
fin.) abAnd-o'numid to the following:
Division ofWater Resouries,bndergrou ad.ltijftdon ContiAPmgram.
1,
6d.Water kvd below ground 14636 mail$mice Raleigh,.NC 27679-1636
Inad-di"ont6sending(befonnio
6r.Outer ca.sing icngffi(if louww6): the address(es) a"re. a1sG submit dne cop), of this fom Within 10 fts of
Completion of well sbmWownent 6 tite onunty heatth depkantent of the couzah,
6f.Inner caiinoubing kngth(if twown), (ft.)
6p,Streen length(if knam). —00
Faim MI-11) NonhCamtim Dep3nmxrd afEst0rowwrit aiA Nqiumt Resources-bivisbonofWateritewwees Revised Aug"2013