Guilford_Well Abandonment_20241001

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
K. Brandon Moore 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Cow i actor Name(or well owner personally abandoning well on his/her property) well construction/depth,only l G W-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
2957-A Unknown
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (Val.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
7c.Type of disinfectant used: _ yp
2.Well Construction Permit#: 24-09-WAHR-00302
List all applicable it,,//construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 8 oz.
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) NResidential Water Supply(single) ❑ Sand Cem t Groy ry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Group • • - '� I.. rill Cuttings
❑Irri ation ❑ Specialty GroutOIC T J 1 2024 ❑Gravel
Non-Water Supply Well: ElBentonite Slurry I ❑Other(explain under 7g)
❑Monitoring ❑Recovery r
Injection Well: 7E For eac matenalsl:rlected aboX'i,p'rovit}Amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete mix 1 cubic yard
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
�.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
(Heating/Cooling❑Geothermal Return) ❑other(explainunder7 ) Poured concrete directly into well casing and
filled to within 3 feet of surface with a 12"
4.Date well(s)abandoned: 9/1 9/24
thick concrete plug installed on top.
5a.Well location:
Buren C. Haggai Trust N/A
Facility/Owner Name Facility ID#(if applicable) g.Certification:
2116 Guilford College Road �5 • oz" o,�,J t-1, 57 A 9/19/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Jamestown, NC 27282 7822-56-6829
B1'signing this form, I hereby eetYify that the well(s) was(were)abandoned in
County J*LV Parcel Identification No.(PIN) accordance 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 provided to the well owner.
(ifwell field one lat/long is sufficient) 9.Site diagram or additional well details:
36.018228 N 79.927862 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 WELLS)IIFING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.Formtdtiple injection or non-wafer supply wells
ONLY with the same construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total sell depth: 136 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (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: Unknown (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unknown (ft.) 10c.For Water Suoolv&Infection Wells: In addition to sending the form to the
address(es)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
6E Innercasing/tubing length(if kit ossn): Unknown (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016