Guilford_Well Abandonment_20230905 (2)

FELL ABANDONMENT RECORD Far 10cmd Usd ONM
TUls foitifadbe useil.foe singteaoi multiple m-dis
I..4Ve"Ctintrac(os Infermuti6m )yELL AB;1N11ONN1 1EWr DItT;k f:.S
Stefan Smith. 7a,Nutuberaf wells being abandoned:
.1
iFrC1CC°a[trac!orh`amp,(4r�icllo�ancrper us�IJyaUOQfaniuo�a.11outi�tlter'prdpcny] Fair rerulttple igjea t(rir o Pdljlotijtar sirpto+ W41S .ONLY wtlb' the swne
Mtitntciivivabix"doirmod.pia C m saal�rrttalzfaNyr,
3576-A t I ,
'7b.Aplproirlmatc volt=of watw i mmiking m ri clo(sjz �g�1
IJCIVACanlraclure_Vtirwalion.Nonirci - f i
SAEDACCO FOR'%.`ATER. UPPLYWELLSONLY;
ConVam•Namm 7e,Type nr d➢sjitfeciai�used: i!
2.Wdl Construct6grt Permit#:,
Lm rdl applimble well pnlmyty#.e.Cwyrtt);Stars,Yni9ame,firJrrtfuy�,rtc►1f Sxmtup �'
N Atnot[n¢.ufilhitifectantuwdi
3.`F431 uei'(eliccl:st'cil ca ie}:
Water Sttpph Wcll• 7c.Scaling matctnals used(clrccl,all that apply)
17r4G?[cttll[tatl' 17>tititriic[p,t11I'iitigic i.l;Nett Ccmcot Gtuitt M gck9oJW Cbips or Pc11etS;,
Alacrniltcrtnd(Hca6u riaolittj;Sujspl}} pRcsidentytt`�;a(cr�}iFp1�'(yin�,lc� ❑S itid Cintkat Grout Ll fhp�Liv-
DUtdtrs6ti;tUt ommetcial l7RWdendaL%Vmcr Supp4(sh+•t[ed}'. .I7 Canctetc'Giout ri brm billings
17Ini tion o Specialty Grout' b:Gravel
NoOm-Water.Su.pptvtVelf; 0 Bentotute5lurrry 13 Othcr(cSplain under 7g)
�lrlonitorine>, bReCoVe
Injection Well. 7f.Foecach atatedatsdected a116%provide atuountaf materials used:
DAijuifcrltccharAG I7Ciruuiidi}�1erReatcili:nicn .
EM41 fifer Storage aid ROCCA-ery OSalioih Border
C1Atltwi tTrst [7Stoivnyaterl7itiitiagd. Sentonite::501b ,Wtr:gal.
OEspeitnie[iial TdcUus([q pSubsit[ptxn Girttttil 7� Prdvidc a Uricf drsci ipdal eflic abandnnmctit i rocedtme:
Ocwibcmfal`(Closed Loop} Otwacer. j
Pulled temporary well and abandoned borehole w/ hydrated
®Gcothemtal(HeatiLOCcoliva Retum) 00(her.(i:mWn unddt 7R).
bentonite chips.
4.Date well(s)abtindoncdi 8/16/2023.
Stt.Wcll Cuathro;
L
Forest Oaks circle K. Ur.j
FacitityXhvtreNmr1Q' Fwauyibm irapp oblaj S..Cet¢itieatloit:; i / �' i
5324 Liberty Rd: Greensboro,-NC 27406 8/29/2023
Pltgskal Addtcss.City;acid Zip S ilnrr;.Ceailicd LVcU i ritucrtot im Wetk t hvtir !laic
Guilford ray,vigging this fdm4 f Lenby certrfy•that Ike we1!(s) was imere),abmidoned hr
Ca.iniy !"creelIdnWi0it No.(PIN
j'' stuurzltr�ticirillrl�Q.�:C1I�02C,;a10t7:ur3C.02t?t)T�e11Coiititn(rliuriSlam&ircfs
or(lllriit gcnp),of1hisrienrdWs$een pfv!iMled to M6i4 dwher-:
Shal.tti(udotntd Irrngitutic iri dcgrxeriniittulscconds.ar•dsctnt;ol tisgicesa .
(ir.1611 rww,ayes WID,11;; s ytttcicta) 9.Sife diagram or additional well de(ails:
You.tnaf use the bkk of tilts page to prtmide di i6nal It site du ails•.oi well
K W aliaudouuteutdr tatLs I'oit n>Jy also.�s9o�U additional pates if ttccy csary_
CONSTR1)C'1.ON.firr.?t1➢..�i 69wc,LuSf BURN.ABANDONED :SUBNiTTAL iNSTRUCTIONSc
,-tttadr tr eR cionstra'rtida rccnrdils)'if aallalili Fr r myylaplr U�ecti,#or ism•n f r mpFdj-
urlb O'NBY yildy the svnre ems irrm(to)tU+ill raby.iAgit,j 4d can sfrbirui wre/W7rt. 10a:-Fnr All�4Vcltc: fst[6mii iliL5 farni'trithin 30.{lays of completion of well
Gg,Wellm§•$-8 ab tndontncntta-the fvllo}viti !` 'g
Division of V4`awr Res"ipcq,.InformaiioQ Pruces4ing Umit;-
1G1?JlLii1 Scnicc Ccutc'r.,•Ralcidlix hC
Gb.Tatal yvetl de(ttU: 20 27699-1617(fCy r -
10h.Fnr Iniectiasn W-019. In ridditioa to seeudittg dk�fatrit to die address iu'i0a
fc:Eiot hole.diauteter:l abow also-subroftLone sop±i of this-forin ivid6 30`days or,cnpt otetiatt of%mll
(tu;) aWndountent to(k fa110tciug
6d.Watetrlcr+ibcltm ttrttl suiFaccc (ft:) Divistou't WmWrRcsattrcc4s,.iiudcigruuhd l61Fe't[on Goitirol Pt.grata,
1636 Mail Scnicehntcr,Raleigh,ANC:27699-1636
10c..Fne Wage[ liggUiy.4 Mite 1tlan tartly: In addition to senditt$(lie foni.to
sc..(lntcr casing lair it(if lmnrrn);.10 M.) the-3ddress(es),aboi,4. also m5i»it.one copy of this:f0mi yvi biu 30 days of'
Completion of ytell obando o=nti to the county heidth deparintc[st of the courrly
wherC a!>ilndonc,A,
Gf.:Inair casinlitalting C�i[ydlt(if lgtotrn j: M., !
G'I.Scmcn Iength(if knoysn)t10
Farm G%V-_30 Nonh Carollirr Depomnctn of Endroamept aut Nrt[uml Resaimes-Di islon of Water+Ri otuRs Revised August 200
I

C i
wELL ABANDomviENT RECORD Rif Idcm:tlMONLY,
This Win CakUe'uied.fo single,orinulliple.;milli
t.Wctt'(;nnt6i;,Wt-Informatititr: NVELL ARANDt)t114IENT BETAMq
Stefan Smith 7d,Number of- ellsOvIngub"daned: 1
lFC1t_Certiractbrh`amc'.(4ri>rltoisecrper tnlJy:. unfne �tell.ueitiFsAte-rprapcsly) 1'6+1 _w1!1'lpk ligew an iw -roatki'air srrpjrlt- tr& .ONLY wah the -snlrie
crinerrrrcN�xa'in6w,Ylrrainr�rr4 aura care,raahartfrxlajirnt,
3576-A f
NE Welit nlricWt Ftitication Nnnitrcr ?It.Appma:rndte ulceiae of irati�I iiniii M ii'ell(sj;
SAEDACCO FURAVATFR.SUPPLYWE I5ONLY,
Convan}•Kama 7e.Type iddisiufectaat 63cd:
j'
1 Well Construetiou Permit 9:. i
fd3tt�lGujiplltrabt�-urllrrmtv :r'C�nut}t Stralr FaHruare Irrjerltata rhYlfkrwra
- jai.attn+iutit of:dliiiifrtitatit ttsed:
3.`Ydt q�c(eLed `vclhFuse}:
water:Supply wek 7e.Si:aNtog matiows used(cl 0 all that apply):
pe+u,,riznIQtW L]?4latnicrp 114".u[ilic l 1,Nrpt Ccnictit:Giout tR 13cr4oWnd Chips or Pellets;.
(y �p}1Af3sntltcrm tl catip�.Cooli St t Atcstler Ut Vater Slip ❑Said Cmtent(mnt i 13 biy(kV
(slngl0)
3lndustrial10omnicmial- DResidendal Water Supply(shwcd) l7 Con�tet Grout j; rl 17ri11 Cuttings
❑Itri tiorr t7 Speciabg'G ouf . b Gravel
Nkii�Vatee.fiu(rptp-Wc[t: C1-bardotube5likay CE'-Otfier(explain under 7g) .
wl4ltinitorinL:_ ORccat�r:. .
Igjc4Ki4n�Vclt: 7f.For each.matct al selected above,provide amount af.lrtatcaials rtsccl:
uifct ccharoc [30niundr0ler:RerncdU1i6n
�tkyurfee Stomge aue!Ctc'cot ery L7Snliiiitt Darrlcc
DklutferTest DStoiumaterDni,Euitge. Bentonite.:bOlb ,Wtr:gal.
pE�tpenµien(al Tecluutifogy 195irtisidei v Ctii nl 7g:PrprEsc a brief d�scriptiari of tU-abandoumcat p[ueiylnrm
t�Geottiernxtl4C�Osedloop}. C1TYacer ''
Pulled temporary-well and abandoned borehole w/ hydrated
�GetiFhetmal{ficttinttlCaa6n&Itetum)` .®Qtlterlea lain under 7 ),
—.— bentonite chips. I:"& .'i�' .5"•FA . ..,
a.pate nel(s).ab;inilonct
8/16/2023- j` A L_ M
Sit.�Yel➢lueathieo: �; 2023
EP
Forest Oaks Circle K lryr;tiCC ? n� �O
S..�crtilic�Glaiuc; i
rceflitc14r+6ncrNaatcc- facililyll'id�Eappliuibldl II - l�o�'✓'a�'
5324 Liberty Rd.- Greensboro, NC 27406 ! 8/24/2023
Phy.sieat'Addmss:Cap:aiid Zip inn Cestifiid Welt frura:uif;r>r Wcet l}i�n r ll u�
Guilford 9-sipa:ing;Iltls frirna,.I hembycer•11fp+-Vaal/Ire we11(#teas(were)ahmidmeed nt
Coeiiup Pwrc)1dp91ifiiWsir No.(PIN ijecUtrkrte ivilhjS4-1CiCD2C3i0100or2C.0209Troll,L'ciirslivaigrjSldmdtirtls
- �addllrot'acbp�rofllrisrecardltas�he"eit prnvided to i'les:iscll ot}•iter,
Sd..tltitndcandliingrtlrticin;cte s?iiinufcslscoWsur•d-CCiWAdcgreti; 1.
0*011 rwrd,ow ;It110!q.0&S llwjaPA) 7.Sit'a dE.*ram or additional Well;der it)s:
Yoit.tua} use the back af.this Vd'a toproride additional tttirU.sito,d iaEls>or'�sell'
hT - - •W abandotauari dctai(s"You tuns'at§oi:utacliaaliitttoiiataxi sif,uecceWi n%
CONCTRUC'ITONMDETAIII(}p1V>rWi4 sElNG.ABANDONED SURNHWAL TNSTRUCTII7T)rs
.4ttarlr mo4l crinaraiefieu raciurdfs)'if ai�3rFaFili. J$v mzfriplr i�grcrPuar iir'twn•pntef`upph-
urllsONLYriftJrrlreenraM_ca!rsuracrlrnrvLrurrWria'eriLiraucvrtsriLrrrtrarefuim llla�i•Fnr.Al1 4Vctts:: Submit.11its;fttttnWithin BO dtr}8 of comitletibn oftiYl!
6a:Well Ing.P-9
abaadonmcstt to ttic fnllotvir►�:
Division of Witter R6*umft,Iuforma6n Processing Unit,
'tt l5 . MY
1617 A1:iilScrvicc�eeitec}.Raleil+Ii,NC 27699�I617
6b:Total tsctt d� the (
f0b.'lrt t'iinleetlastt Welli<: In additfou to sending dkg forat to the-address in i0a
fie:Borehole diantcter:l aibow.also subadt.one iopv-of ihis.ftir»i tttilhiu 3U darys of couipteliou of.►eell
abkdounmui to the fallowinx
Gd.r,Vater lecrl.bclme ground sttrface'� (ft} ivision ae Wmter Rcsous7ees;Uuderground Inject['u Conttvl Prgl rapt,
1635 Mail Scn•iCC�Conter,ItaleEgh;ll G.2aG%9-J636
10c-Far M kr•. i n1 -Iulcctl fn Wena: Inaddhion 16 sending the fomr.to
Gc.Outer casing lcri U.(if imowtr): 5 (ft) tbe.:iddress(es) ab06. also mUnii.one'copy of this fban tviihitt'36.days of '
1.
complction-of well ahandmuneati to the taunty licirttb deparimeni of lha coinity
«deer>;alrtrrdotrcd•
G6 Inner casM4 liiva teny-th(if linown): (ft.)
6,;.Sheen length(if lmaiw n)t lu A)
Fume my-30 Nanh Cataliro Depampom of Envirommot a.W Natuot Rcsowces=Divisiau of Water licsourecs Revtscd Augw9 2013
I
I

WELL ABANDONMENT RECORD. FailrAemtll3sa0NLY:
Thisfomicaiib'd'u edforsinglo:ormultipte.yrells
1.WC[I,CnutrtM r Informdtione )YELL ABANDONMENT DETAM4
Stefan Smith ?a,Number6UN4lliheiny"bandnned:.1
dYclfC'c�meEorlwamet4r+ielluirrsipertasiatlyala�sufaninnstrJl.O>tliL9iltcrprnpcnyl P 1' ppb,
far alit/tt k tti rdwr .cw taut Ytincr 3rr A ua11# ONLY Willa Me -mile.
. - roJfsfrnclttxa,�rbnrrlrtiuNcntl.;mricimstt tlFnttefurtn;
3576-A
NG fVeil ConlrlraorC¢itificalioirNmnbci '711.Aliprririmatc rol'c of vFat tr2teiuiuiug ua 1ti'I(l j:. (uL)
PI
sAEaAcco FOR WA`F1.RSUPPi,YNMI SONLY;
Gotoan Naetts. 7� Ty'!ye ofrlisinfititant ri3eel:
2;�Velt�ansttv�Yiou.Pcrmtt#:� _, I.,
Ltsf all Vol 1401r well permia i f,e�t.7idm y.Srati,bnHink-d- rjrrttut�,c!c 1 lfkJruwn t.
7d.Amoun e.of:dlsinfectant used:
h
3.Wet1 us"�(cheri:srcll u�ie}s i. .
rYaber Supply Well: 7c:Scaling matlidadsiiscd(011; l all that ajiply);-
[7 r SricitktiraB . 17hfitriictp Q/i'ulilic. �1:Ncat Cen+eiil:�stuat -13 Bcnt0 tc chips or Pallas"
�IGctrthcrmrt(41ea6j C9olit>z,Supply) L]Itssidcntipt�V,iter S`ipp!}'(itiglcy L1 Sand Cetttcnl Catnut 13 Uty 014y
13hidomialMomn+cn:ial- Mcsidendal Water Snpply(shamd)' O Cgilcretit'Grout - O Drill&t1in_2,s
❑lrti lion ' `b Specialty Gtoui b G_rar�l
Nu-WOOoSulrplv"'>sEe: CIBen#9nite5lutty ®UthGr(ei7tiainut►tler7g)
®INotiiWrlue:_ t3Recoveiy
[ajc4Kion�VcII: X Foe each,material selected above,provide amount'af:rt rte lais used;
OAijl6ifer RecGarQa i7Grgttiidtiti�tei•jtenteaL•Itioti
OAgrnfrr Sordge atxi Rectoveiv [7Sulinih D-lydcy
OAqutfcKTest OSiornni�letUniftiagd bentonite.;5011i ,Wtr gal,.
131i\paintenlai Tirlino[oly d5ubsideuce Giioml_ ?u l*ri►ride a hrtrf discriptioti of the'aii iadoumcaf p.r rceduri i
MGeo►hermifflfoscd.Loop} Mracer. ;
Pulled temporary well and abandoned borehole w/ hydrated
®Geothennal(HeatiaE ooHil Retam)' .®Otht:r(ex lain under7a), r
bentonite chips.
d;Datc�eU(s}_ahandnneelt B/16/2023. �; �' �
Sa.We lucattote:
Forest Oaks Circle K i in, n rPm-c �4j 1.pj
`.&Certl(l iiioa::.
FaCilitrJt7n•ixrNnme racilily>pp f fappliCabtc) ,
5324 Liberty Rd. Greensboro, NC 27406- �_ �- ,; ,
8/24/2023
Ph ;}sieal Adikess.Chy aiidZip �jiu4,.C•citill d%Yell Coiuravor+r Well bisno 1]rue
Guilford Ify xt ririg•11tis frft�rt, f lretiby cirtlfy flmt!lre;uellfs)itrrs(%sere)afittna'aned nr
tocw). P.imclldcril3t?60itN6,fPjNj nuviYfritate:trf!lrlS:f:4C11COZCi;fllQtl.ur2C.11200TYellCrtii57talrUUriS#trrtihirils
nnil'tlrii!q.copl�oflairsrecordliusbeetrprovitled1"wrc.li llnt+iier'.
Sb::J}atihide and longitude in:elesliaiFnutcslsccarrls:ardcciittroe degi+ccs: j ,.
ti#�tett Ca[d,Ara 4�titoita .idticaetq) 9.Site di,'igrant or-additional Veil.dc¢at(se
-You.%nay ust;llie bars;of Was page to procicle aiDdirional tt>11.site dzttitlstor hell
N elf a6bantlatiruaitt details:Yoo tuaj algo'tutacti 3dditiati2l poems if necessary.
CONSTRII4"e'IONL bETAIUS 011 WCLQ!til BEING ABANDONED SIMNIFI fTAI,iNSTRUMON.S
:[1fiuL urfl erurrtre1dierrt i!evril(s)'!f aiit dAL I•ur mtrfliplr Uyr410r aY ram•+rater.suppdj• I;
+telta O,yCY+iitli llua 6YlJtrc cw�+firxrtmt/rit rurrW,traeul.j uu can srrLirul am for rc Ma: For All Wd s: Sulrinit this rarm ir[tltin 3b of completion of dull
Q.`Yell mil•B-3 abanddnrncitt tu'thc follaiti7na
is
Division of Wat&Rizgourcm,-Informiltion-Pruceming Unit
20 lei! 4Lil9�nicc!ctiite,,Raleigh,NC27699-1617
6b. chit well dol<the ((t)
106.1?na Irfiecti+iri Veal :-In:iddi[lon to sending dug;f6mi to the address iu 10u
Batt%tole dlauietcr.l abotv,•also subulU:orte rupv-of lhis.tonrr rsiWiu 30'days of Compteilon of melt
Q w abarid6ti tent to(he,rallaliiug:
1livislor.of Water 116onmiesjbndeigruund iojeolou Coi ifol Prggr•uiu,
rid" Water fi i*dbefow gm nd anefx& M.) [G36 tllait Senice'6nier,Ralc[;h;INC 27699-1636
110c.1'nr Wtk ar 5 u unniv aF lWMf %Vei�s: Iu addition to scodiag the form to
Gc.Qutce casing len 6.(if lma�o); .10 M.) th9 addmss(es) abo'e, Aw sWinit_One copy of this-form within-34 days of
coniptetion of►%:ell abandoritnmt�.to itic county l"Ith depadmem of tare county
6f dnacr cJsin/tn(rint;Carl th if hpow•nj: (ft)
n'hrtc abciridoncd,
6't..Scrceit leagtlt(if lutouti)-10 (ft,)
Purnt GtV-3tl NonhC=Hmtn Depammm of ntirounmot au]Natuiat Rcso=cs-Division of Yratcr R oiuccs Revised Aitp512013.