Guilford_Well Abandonment_20241001 (3)

WELL ABANDONMENT RECORD Faf hxcr 11 t W ONI v
This form can lee used for single or nuiltiple wells
1.Well ContraMnr Indirniation: WELL ABANbO 4MENT DETAILS
Chris Ruffer la.Number ref r%dls being;shandnned: 1
Well('owacr)I!rant lot ucll 1n.Iwf perxaulh Aunknxllg t.cll on hlsrltcr propem flv mitlrpk olle0kn1 or a wN ,Ifer ,kpph .ells OALI teeth I&- .fade
.,Npfllp rwl.d•,nahatMkrM L.a..an v,l.nur wt. (.mm
4223—A
NC Well CnmmcrnrCcHifiwttnn Nxnttrr
lh.Appnf%imalc%clunk Id'i%,ucr i vittaininr to acll(iii: Ilhlal l
SAEDACCO FOR N TER SVPPI 1 %%fl I�0\1 1
Cottiliw>Name
7c. IN pc of di.inkrlant n.a•d:blench
2.WeN Constructiaa Permit(r,
luredlnyfrilxvble well prrwav a.e-t wM.VL*e.Ianaw-e 1"N'hofc eft..fIbw 7d.Amount rf di.infMA"t uwd:•5 cup
J.Well Use(cheds%%ill nae1:
Water Suppl}Well: 7e.Sealimq material.u%cd(cbecic all that apply):
❑Agmulniral ❑Munkipal,'Public ® Neat Cement Grout F1 Benionite Chips or Pclkts
❑Geothermal(Ncanne C'oolin_Sttpplcl ❑Rmden nal Water Supph ising1c) ❑Sand Cemem Grout ❑Dn Cb,.
❑lidusinall'ommcroM ❑Rcmdential Water Supple ishared) ❑Concrete Grout ❑Drill ciflungs
❑Irri :! ❑ Specnalh Gran ❑Gra%el
No*-Hater Cl BertoniteSlurn I I Other(explain under 7g)
®Nlonuonnt! ❑Roemer
Injectinn µell: 7f.For each material.cleated altose.proOde anwwrnt of initterials wwd;
❑AgnderRecharge 06roudaalerkeniethation Neat Cem.:351b ,Wtr:3 galgal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Reco%en ❑SAliltin Hama
❑Aquila rest ❑Slontmaler Drainage ----- ----
❑E\penmcmal le+chnobg,% ❑subu enceCortrol
7>;.Pnrridr a brief description of tlw abanrbntrtcnt prnutilure:
❑Geothemwl(Closed Loop) I-ITracer
Tagged well depth. Chipped with 3/8 chips to 15ft.Put grout
❑Geothemnal Meatingkooling Return) I(Other icxplain under 7 ) -from 15ft to 0.
d.1111aftt1lrtlhs)ahandoiwd:
9-9-2024 ` e'"#
Sa Wed MKation:
A Cleaner World p188 8,Certification.
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FocBit>:townor Wnne Facility MA!(if applicable► 11'f:�:F a.i•'+} �I�t►,",y� }�
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2525 Zastohester Dr., High Point, NC 27265 Chris Ruffer 9/13/2024
Phi sisal Addrem.Cih.and Zip \ioname of('edified Well C'oxsacbm or Wea Owmer Dore
Guilford Bi signtrox then jam, 1 hereby cerrr/y that flee well(si was!Mere/a6madmied rtr
C'otral% P u.el Itdcf 11fe::likM N., :111\i acra nit rrn•e with I1A XCAC 02V,0100 or(-.O:IIO Well C iwslruc7ion Skmdards
tmd thief a agog of Aria record hers hem prm-mW to the well owner.
Sb.LaHtYde and bnditude in de)rrr.;mimrtevvrnnd.err decimal daxnvs:
0f well fib otie lavlong to wtticwtx) 9.Site diagram or additional%01(M•rails;
You mat use ilk badk of this page to phn ide additional ueil site details or%tell
\ W abandonment details. You ntay also attach:ddutotial pages if neccssan
CONSIRIA-PION DETAILS OF%\ELIASI BEIR(:ABANDONED SUBMiTTAI.INSTRUCTIONS
.Ifkn it keii ae,ntlrkJr:nt rr.urd s:jJ at udaahk 1—nnl/rplr e0tei "If tlr Wifl-0111V%Ujy-h -
welkONLY with the MAIN,t#mawt rN,n ah vrtAlt~ii.i,,w can n hmii rote horror IOa. For All Wdb• Submit this font ultbin 0 dar%s of conipletion of well
Wen�: _5 abandonnicut to the following
Di%Won of W ster Revuert:es.Information Processing Unit.
6b.Total wcr depth: 35
1617 Mail Smice Center,Raleigh.NC 276'Nr-1617
I fr.►
lob. For Inicclion Wdla: in addition to seiduig tIR funn to the address in lua
6e.Ibreltokdlttmekr 2 lin,l abo%c. artso sitbnul otic copy of this fonn%%tlhw to days of completion of cll e
abaidounicru la the tolloutnt;
Mislox of Wider Rewrumn,Underground Injection Coniml Pmraw.
ad.Water byti hdnw tprtsrrd%urfarc: 10 Jft.)
1636!11ai1 4nicc Cater,Raki8le,N('27671-1636
10c, For Water Surwrh & InkrtMlw W b: in addition to sending the fonn to
or.Outer casinf length tifknohni: (ft.) the address(esi abate. also subside one cop} of this form %%ithin 11) days of
completion of"ell ab.inditmiunt to the county health depannieri of The coum
6(.Inner carin-_,,'tubim;k-ng4h(if Isawnl: 20 IR.1 a Ivic ahandnned
6g,Scrern Icn(ih(if lm4prin1:15 (ft.)
Four GW-in North C'amhra Dcparline a of Ent iromitenl and Nowlal Remmoices-Dh isio■of Wald Rowax%s Ray ised August N)I(