Guilford_Well Abandonment_20221104 (2)

WEMADANDOl\1r N 1s.111GCORD For iMMI Use.ONLY:
I
1;We1l,Contriictor:linformation: WELL ARAIVDONMENT•RE—TAM
Fyn c�.Ga.m eS . .I.c,k r. re r 7a6ForGeoprobe/DPT'ot Close&Loop:Geo'WeriW Wells having.the same
We11 Contractor.Name(orweq'owner petsonatty abandoning wetl on hislleerproperty) well constructlon/deptb;_bnly 1 GW 30 is needed Tndicafe TOTAL.NUMBER of.
wolls•abaadoned•
N WeII:ConnaccorGeitificaHonNumber 7b:.Approxitmtevolemeofwaterremalninglnwell(s): ( �)
_eA\af\ 1,k M D .1,ke—• FOR WATER;SUPPLY WELLS ONLY_-: f�
7c;.Type of'dislnfectant usedd-, 1b l �°
2.Well ConstructioaPermit
ZW all applicable Kell constrnchon permits(Le.UIC County State,xariance,eta)(f known t1
Id.Anioont`of•disinfei�titused:66.:• G\ ...._. ._ ;
Water snpply Well: 7e.SeaUng materialsMsed(check ali that:apply):
D.Agricultural - i7 ctpaUPiiblic ❑�t•Cement:G=om -:[]6entonite Ctiips.or Pellem --
Meothennal.(HeaUrig(CooimgSupply) C%]Itesidential WaterSiippiy-.( nglej fd Sand"Cement Grout O lhS' Y
nlndustriaUCommetieial`: aResidenW wAter SuQply:(shared) .:O Coniiete>Gmut. 0-Driil Gutflip
13kri •on .17 SpecialtyGrout. D:'Gravel.
Non-Water,Supply W 1.-- t t
PPl'.��_ a t w.�- O:9entonit681My IJ:Othec(eriplatnunder7g)
OMonitoring Recovery _. .
�f'For:each material.seleted above;-provide a>ngnnt of mateiials used►;
Injection Well: 2Q2
DA fer R OGroundwater Remediation ,r I
`p" N v -ulna c1. 1.� l�.t 5 4: ��cpt�C CC mC,t1�' `t©u�$
DAiluifer:Storage arid:Recov pq r�,eCImtty Bamer , I
DAilaiferTesG 1n�`'r' gyp; i`3StormwaterDrainage m a
OFrzperimeatal Teclinbtogy D$ubsiderice Control 7g;;Provide a tiriefdeacriptionof the:abandontiientpruceduret
:Mwthermal(CWed OTracer f('�- I y��
OGcothermal eatin Coolin Reinm. DOthcr( lain.urid&? �C'.fs`���� Je� Q 4L�tom. � rr.AcA\ r� i e1 �
' i
4;.Date•aeii(s)nbandoriedi ® �7 a.ml? -r r�G,� d e 1` ( lAY F: �...t P G r ` �°
318.Welllo`cation:: (� Y W iM' 5'ou-\A _Car-Ne-4 . (1(®LA M 1C-
\ h i 0. ��D�kG�• i neh W. r5���llOt ��Oc�G� vrC�L e�,Ll6g 9l`�'C\-
r �' n Li:rcl.we�o ee�h
FacilitylOwnerName .paeilityiDlF,(ifopplicable) S,Cerliflcatl0 pe / n
Physical Addras,City;and Zip S' ° sure of Certified W hactor or Well Owner
-- 3- 1 '4 dgwing-this,�otm,l'•hereby ceri that the w¢ll(s).'.t+ms(were)abanddrled=ur
County Pareel:IdcntificanogNo.:(PIN). accordance with 1SA NCAC 02C.61d0-or-2C,17200 We U Consfmdion Standards j
j:. and that a cqWqfAis,rzcordhas beetpYovitled tollie.welto►vner
atitnde'and longitude In degrees"uWAeconds or decimal;degrees:
— Cfwcll field,.one latllong=3s sufficient)-_ 9;gibe diagram or additio�l Well detaila:
l $3 You.may use the.back oftius page to provide additions►well="site details,or well ti
abandonment°dotaris. You may also attach:additional;pages if necemary.
MNC7 RUCTIAN DETAQS OF WEI =S1 BEINGARANDONED.
;SUBMITTAL INSTRUG"l[QNS'
Attach:welleonstrttcNon:recw.d(s):ifawilable.Fopmul*kinjectlonornon-waterstq�pTywelLv
ONLY:Wth the smne consoucdoa/obandonmim you can submit one form ...
10a;;-For.Ali Wills:,Submit this form within:30 flays of complehtiti:of welt;
abandonmentao the following
ba.Well M#r.
Division of Water'Resour+ces,;information-,Processing Unit,
6 .Tofalweli-depth:, � (ft:) 1617 Mall-Service Ce�ter,Raleigh,-NC Z7699-1611
10b: inl tlon We0 I addition;to sending ibe,fortn to the address'in:IOa
Ll
-above,,also submit one: of Ws'form within 30:days.of:completiott of well
6c;Borehole diameter ( •). abandonment to thafollowinF.
3 Division:df Water ResourtxS,Undeiground Injection Control Program,
6d.Waterlevel:below.gronnd sdrfaee: ( ) 1636:Mail Service Center,Raleigh,.NC>27699-1636
�. lOc„Fdr.Wiiter:Sobnly 8i 1Z jectioni Wells:In addthon to sending the f6rtit to;the
6e:Outer ea§ti g teugth(iikrtowu):',_ - ( ) y( ) vefalso,submjt one:eopy ofthis form-witbm 30 da_ of eom lesion
ys P
of,well abandonment to--the county health.department of'the'county where:
6f.Inner csstitgitabing length-(If known:�kn (No1(ff:)d w abandoned
6g�•Sereen-length Ofknowujr_�
Reviscd2-22.2016
Form GW-30_ North Carolina Depattaieut of Epvwnnlental Quality-Drvtsion of WaterResoulees

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