Guilford_Well Abandonment_20230602 (5)

WELL ABANDONMENT RECORD ForinternalUseONLY:
L Well Contractor Information: WELL ABANDONMENT DETAILS
David Hardy 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Welt Contractor Namc(or well owner personally abandoning well on his/her property) well constmrction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2906A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
Aqua Drill, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: r�Y
2.Well Construction Permit#:
List all applicable ivell consonction permits f e.wC.Comrty,State.Variance,etc)if/aiowa
7d.Amount of disinfectant used.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑Sand Cement G glut :, �-fl•D Clay
❑Industrial/Commencial ❑Residential Water Supply(shared) Cl-Concrete Grout["� -Drill Cuttings
01nigation O Specialty Grout j I r, Gravel
Non-Water Supply Well: ❑Bentonite Slurry J u N V d 202�Other(explain under 7g)
❑Monitoring ORecovery
Injection Well: 7f•For each ma �° "'" ''
❑Aquifer Recharge ❑Groundwater Remediation � 3laeTected a6ovi;. roVid amount of materials used:
�/di>a `�/`�a
OAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stomnvater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer f /
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g)
4.Date well(s)abandoned-P''23
5n.Well location: J
aeility/Owner Name Facility ID#(ifapplicable) 8• tifieati
Physical Address,City,and Zip Signature of Certified W Il C or or Well Owner Date
&-un", &r� By signing this fonn,I hereby cent that lire weH'(s)was(were)abandoned in
Parcel IdentificationNo.(PIN) actor dance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been pr oWded to the well owner.
(Twell field,one latllong is sufficient) 9.Site diagram or additional well details:
,r lv) r 1 '7 j� -7 N 7_f� X- `f W You may use the back of this page to provide additional well site details or well
//, abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constnrction records)lfavailable.Form�lliple ie jection orrron-rtttrersapply rvells
ONLY with the same construction/abandonment you can submit oneform.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: _(ft) 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: _(in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,.Raleigh,NC 27699-1636
6e.Outer casing length(if known): 00 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
addresses)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner casingitubing length(ff known): (ft.) abandoned.
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016