Guilford_Well Abandonment_20220711

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WELL-ABANDONMENT RECORD ForInlemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Timothy D. Leatherman 7a.For Geoprobe/DPT or Closed-hoop Geothermal Wells having the same
/ Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
F�a wells abandoned:
2888-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Pyramid Environmental and Engineering, f FOR WATER SUPPLY WELLS ONLY:
Company Name
A' 7c.Type ofdisinfectantused: Calcium Hypochloride
2.Well Construction Permit#: 'V A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 1 pound of Ca(OCI)2
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) eResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑IndustriallCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Cement, sand, pea gravel, grout, and
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StotmwaterDrainage no fly ash ! 1.25 cubic yards
❑Experimental Technology []Subsidence Control
❑Geothermal(Closed Loop) ❑Trao
7g.Provide a brief description oft he abandonment procedure:
Excavate down 36 inches; cut PVC casing off at 36 inches;
❑Geothermal(Heating/Cooling Return) ❑Other eFp mu 8
"`"• Chlorinated well using;1 lb. of Ca(OCI)2, then direct
a.Date well(s)abandoned: 07/06/22 JUL 11 2029 pour cement into well until casing completely full.
5a.Well location: MR&IwTal Completed cement mushroom over well casing.
Mercer/Kitchen Property W Rj.T=PROLE :sue`'G UNR
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: j
805 Woodbrook Drive, Greensboro, NC 07/06/22
Physical Address,City,and Zip Signature of Certi 1 d Well Contractor or Well Owner Date
Guilford 7835538331
By signing this form,I hereby certify,that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.091419 N -79.894247 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 tivell construction record(s)ifavailable.Formuitiple injection ornon-water supply wells
ONLY with the same constructionlabandonment you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
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6a.Well ID#• W-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth:
108 (ft.) 1617 Mail Service Cienter,Raleigh,NC 27699-1617
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10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 Cin,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: j
6d.Water level below ground surface: 8'1 (fG) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 7 69 9-1 63 6
6e.Outer casing length(if known): Unknown (ft.) 10c.For Water Supply&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
6C Inner casing/tubing length(if known): NA (ft.) abandoned. I
6g.Screen length(if known): NA (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016

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Supply Well
Abandonment Detail for
805 Woodbrook Dr. (SW-1)
8-inch diameter borehole with 6-inch j
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,diameter steel casing to unknown depth f
Surface
Well Fill Material: 3000 psi cement
pea gravel mix(no fly ash) 6-inch PVC casing cut-off 3 feet below ground
surface
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Unknown Casing Depth
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108 Feet
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Supply Well Abandonment Detail
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Mercer/Kitchen P ioperty
805 Woodbrook Dr., Greensboro, NC
PYR�AM 1 D
Guilford County PIN: 7835538331
ENVIRONMENTAL&ENGINEERING,P.C. {