Guilford_Well Abandonment_20241001 (2)

WELL ABANDONMENT RECORD frpy
Timis form can tk used for single or multiple wells �XF=
1.WeN Uvintrasmr Information: W'F 1.1.ABAVD(/LAMENT DETAIL S
Chris Ruffer 6 'A.Number it(wellsbeine abandoned:
l
Well(bnraikANsnalotrello%ncipemiull. aAjidmmng well onholrtprop.nyI 1•u" w0of-k ailetit.w rV" rM.n- sfo- fvjyVi .ells ONLY wrrh !Me .wnr
rvr/lYlfgt nr Nt•>✓•r I.FI+Wpq'/N.1•rn row•plunll•Nlr'hr�pt
4223-A
NC WcII(7mmnetor r rnifk;Nmn Nnn#itr 7h.Apprirsimate\nlrrwc of water rrmaining in wcililap (Rol l
SAEDACCO FOR N ATYR SUPPLY%%TI.I S ONI.Y:
Convex)Name 'c.'IN pc of disinfectant used:bleach
2.Weil Gnmrction Permit 0-,
lice sdl rgnla rAk welllsvprir..n.e (uiM'.S'rure.l artawcr 1xwe fxxt eh".t tlbuw i "d. \mlrinl of dWnfititanl u ed: •5 cup
J.Well ux(check-well usel:
Rater Suplil�Well; 7e.Scaling materials used(chccle all that apply):
❑Acricultural ❑kdunicipal:Pulik ® Ncai Ccoicm Gram U Benionitc Chips or Pclkts
❑Gmthamil(Ncannii;K'oclinr tiiipph l ❑Rmilciatal Water tiupph ism¢lel ❑ Sand C'ernew Grout ❑ Dr\(U%
❑IndusmaU('ommcrcial ❑Rcm(koral Water lupph msharod) ❑ConrirteGrail ❑ DrillCutlings
❑Ion r'twn ❑ Speaalty Grout ❑Gomel
Non-Water%upply Well: ❑ Bent4mite Slum U Other 4evplam ceder 1g)
INNioliionng ❑Rccus en
Mitntinn Well: 7f,For each matrtial iilectcd chose,proOde am oont of matcriah owd:
❑AquderReclinge ❑Cirtoido terRentedcuion Neat Cem.:351b ,Wtr:3 galgal. Sand Cem.:lb ,Wtr:gal.
❑Aquder StotaW and Rtxaen ❑Saloun Hamer
❑Agmfer Test ❑Slonireatct Drunave — —
❑Espenmemal 1 cchooloLn ❑Subsidemmce C'orarul 7g.Provide i brief description of the abanchininent procedure:
❑Geothermal(Closed I.00pi ❑Tracer
Tagged well depth. Chipped with 3/8 chips to 20ft.Put grout
❑Geothermal 1Ntaun '(ooling Retum) 00ftr icxplam under 7g 1
from 20ft to 0.
4.Date wvil(s)alialdonenk 9-9-2024
Sa.Well lociti ln:
A Cleaner World #188 �+
rim;INN(lwncrNam Facility WO(Wapplicabk5 R ('crtiflt'ariun; 1f���.F�i.f•k'. A'".Y� � �.�
2525 Eastchester Dr., High Point, NC 27265 Chris Ruffer 9/13/2024
Pk+steal Addresa.Clh.aid Zip 4enaure ul(C lli`d\\..I I.nRcciM ur WtN Orvacr Dale
Guilford lit.•.vjgittrW thry/twat. I hereby cernA,An the im•eBfs) wax(were aharmdoned at
n•.�.0�h I'.n.d ktenliticallini No.(PIN) "t-vnlunrc w role 13.4:VC.44C OX.0100 or X 0200 Mell C on hworon,Van(AirdY
and that a cvpy of tln'a record Itm•been prom'tded to the well owner.
. I.atitudc and longitude in de-Merrmimrtrvvvinds or decimal degrees:
dl well field.one Lit{,•u,•i..n1t1:1"w'i.: 9.Site diagram or additional well dttt s:
You nlat the tlk balk of this page to pea ide additional wmell site details or wed
N _ W abardonnicri details 1'w nun alxi ar(ach addnwimal pa@es if rtaessah.
CONSTRII(`IION DETAILS OF\\ELUM BEING ABANDONED SUBMrIT.AI.INSTRUCTIONS
.ta.x/!Neil tvarlflitir+m n"e .1-v{l orwharrlc rinua;•le at"lO.nr rtr rr,n n.uer w/T•v
"VilsO.\'LYs"ifhthrNxnet,mrmn.. .arlarrsArlpnrnl.iorrcurlwhmtlrorepovir. Ilia. Fur All \\t•lL%: Submit Ihts form within 3,0 da)'s of completion of well
6a.R'ell IDmt:mw-3
ah;ndoonicru In the following
Di\isirm of W ater Restiar es.Infortrmation Pruccssing Unit.
rile,Tool well depth: 45 If1.1 1617 Mail tienice Center.Raleigh.M'2'tr1Nm-16t7
10b.For laiedtoa Weil&: In addditni Ili scidma ilk form to ilk address Ice Ria
6t.Rtirvludr diantaler.2 alw\c.also submnit one copy of tins form\\idnn ;u dass of completion of well
lin.l abandonment to the following
Division of Water Resourr",I"ndergriound InkYtion Control Program.
6d.W once k\\i hrhiw r moral wiiarc: 15 (ft.l 1636!Nail Scr%ice Center,Raleigh.N('27699-1636
10c.For W'alcr 5ummly& MivYtion Wells: In addition to sending the form to
Ile.Outer casinlleacth 4if lnowni: 1h.1 the addresstesi abae. also subnmil ork copN of this form within 11) tuns of
completion of well 3b:wdonmcnt to the :ounh health depsament of the Calm
where alatdoncd
6f.Inner casinglahing length 4if laown): 30 (ft.)
6k.Screen length(if kosmn1;15 (ft.)
FonmGWau Noah carobrot?cpannAtvofEmwitinteid aid NatwalRewioccs Ito rcdAagu 2101k