Guilford_Well Abandonment_20220818 (6)

WELL ABANDONMENT RECORD Felt 10cmi„Us�ONLY:
Thbsfonn can be used fot single or multiple_wells-
1.Well Contraetorinfwmation: WirLL ARANDgNMENT DETAMA
I
Brian Ewing 7L Number of wells being abando6e8: 1.
Aldt^Conteact9Nacne(mrttittuwncrp�an�t11°.ol�t�ttinlnaa llonhlitiiert+rupertyl fa na�rira(1M Prl}e ic++r a raMtitte� supph rrad?e t?\'LY wPtlr eJae one
r✓wa�n�rrsur�u,�ivhruxlvrarmarnt'iran cwr�ulun'r tiw�fnrtaC
424o-B NG ArC11 Cbnlr�aar Cenifmalion Nmnteer 71►.Appntitimate valunte of t+rater,tentAi»ing in W011(s):
SAEDACCO Inc FOR♦VA'I f R SUPPLY►IO L.S O LY:
C,Gvvzmy Kame 7e type of disinfectant used:
2.Well Construction Pernit#:
L.W.d1 7d:AmottoI ordisinfect9i.nt used:
3.well use(cfteel:Vidl aw):
Water Supply Well: 7c Sealing rt►atorialc n3cd(eh k oil t_at supply):
pA*arlrural QN11 tnicipatlPtiblic: Q Neat Cc'ment•Crrtrut IN Bc%ottite Chips or Pellets
O thermzel(NcadngrCsotittg SuWty) ❑Rcsidentiat Watr~r Sfipph Csine)e) ❑ Sand Centtlo Grout ❑Dry Ctky
❑Industrial/t ommaciai ❑hesiderrdal%Vartcr Sitppl},(shared) 0 Conc-eete G10111 ❑Drill Cltuin—k
❑Irrl °tiort ❑ Spec alty Gtttut ❑ Gravel
hnn:Waiter Supply Weit; 0 Bentonite Slurry ® Other(explain under:7g)
t7Moiiltotii�, ❑1taoiie�
Injection *Vcl:, 7r.For each material selected above,pr6lvidc atuountof tnnte2lalstttsed:
❑Aigrtiftt ktcliaa*� ®Grritu dti4Hter lieinediation
OAyurifer Stonkg:said Rerztt`ay O$stlinity Bander
❑AgokifdTest 13S16rMW&1erDrainago Bentonite. :150lb ,Wtr:gal.
❑E:tpeaiinentul Technoto t+ DSubsidence Coi ftl 7g.PrOide to lir"icf Acscription of the alraudnntncnt nr+►G4Aure:
11Geolhen=l(Closed Loop) OTtacer
Removed DPT Tooling and abandoned boring with hydrated
®Geothemtal(IieaGo 1Coati Return) 00ftr(explain under 7 )
bentonite chips. i
a.Datewdl(s).nhandoneti'. 06/25/2022
Sa.Well hication: � `
Former Cotton Mill Square Site Pm sorv.ns Un4
Facfl'rivlC wttcr Nana rat tM),tPO ifapptitabicY ti. t rtillc tioir: ao' r OC3
801 Merritt Drive Greensboro, NC 27407 B ria Ei n,� 8/10/2022
Physical Address.Gih,`midZip Smarm riff tiiiied W1ett�firlir lof•w`l zrttl Owme Date
Guilford >~3t .v!S7-dyw this-farm, t hemby certffy thW the we•ll(st teas(were)atie idonerl in
Caiitiil Pstrcl ldentifici ,Wo.(Pilm) oompdahte*f1h IM'XCAC 02C.b100,rr 2C.02/ltT ,SYimdords
and thrar a copy of llris rreeord lraa&ew prm4ded to lire well awite;r,
5b.lattitude and Iringhu*in degmestmirtut6kcands or decimal drgrecs
(;t«•ali fled,atie L tAmig is q1e xk VA) 9.Site diagram or additional hill dctaif:s:
You tril use tlii back,of this page to provide additional nett site details or well
1\ W abandonment derails. You may also attach additiona[pages it necessanr.,
coNs't'R1iL`t`mUN DFTAl1s OF 1VTIA411; lilitN(:ARANDONtf) SU1111iiTTAT.INS fRUfT10Ti5
:ttr�r vie!!crarrirueaivlre rrt�ir�tts7'ti'ovrrt6rahk_ 'f?arrirLtta,�k it},ecftr»rrxr n�vn-+rcn�ur.rarjysl_t '
Uvils one with tha same ro#iwvP r(ioat'ea.Aa i*.k'Mierar.,Itmiam anttint rutr iCmn_ IQa. For All Wctts Suhiitii tbk foam tt thin 30 days of cnmplctian of hell
6a,Well 111M`CAT-42 abando Mcni to the following:
Division of Water Resv urees.Iafotination"Pracessine Unit.
6b.Total well depth. 77 (ft,) 1617 Mail Service Gaiter;Rale'og IBC 27W)-1617
10b.Fer ft t(tm A'ells: In addition to sending the fonts to the address.in 10a
6e Borehole diameters 6 fin.) above.also subillit one 'of his Torn 8t`ithbi 30 daF`s of eotm letlon of%*11
atttaddonntew t0 the folletvving_
rEl Water Iesel Leiria(fround surface: (tt) )aiviiSihn of Water Resourcesh Underground Injection Control.Pirogram.
l63G i11ai1 SehiCe(enter,Raiei;;lt,NC 27699-1636
fir—Outcrcaan ten if Imotsn)• (ft) the10c'a er ear above. a alsubnbn Wefts: In addition-to sending the for±o to
fi �'( ( it one copy of this form iiittuti 30 days o1
cotnptetiau of ivet1 abandounten't io the county tenth depimnictd of the crninty
tt abandoned.
6f.inner easine,;ltnlrini;ltntgth(tf known): (ft.)
6g.Sow#length(if known,'y
Fomi GN-ln North CaroHm Dep3ninierd of Environrmat and Natural Resources-Wvlston of Water R'esowevs Revised Ariptsi 20 B,

NVELL-ABA"QjNMENTRECORD Fay Werikil Use ONLY:
This fbim'cafi be Used fbir sin 9k or multipte VW]s
I.WVlI Contractor Infonnation: )NELL ABANDONMENT,DETAIAL
Brian Ewing 72.Number of wAls being abmndo6ed.
Fff m1daple fqkdrcur or flou-Njilter sirpPly wells ONLY Willi IAT "le
4240-B
7b.Aplortwimect-oluiaw of vrattr�lrernikining in (99L)
NC-Well CoutrarAor rdHification Nwriber
SAEDACCO Inc FOR WATER SUPPINAMLLSiONLY.-
ConwitylyName %TAVe(it dishifectant ukth
2.Wetl Construction Permit 4:
Lw d]4pplimAk swilAcrxiis(i-a.Cown.h-,Siak,Vaffamv,btfMiari,err)1fk1rr)WN 7d.Amount of disiltifectant used:
3.Well
Water.Supply Wet]: Ir-Scaling maticri'sis used(eh6cl,all apply):
Oftwip'lltittal 0 Ncat Ctmcn(Gmuf N Bcoto iiii(O'ChipsorPollets
0G4vjlwnnal(1-11CO611jeCoolin-siapply) Okcsidemial%vote Supply(5 El Sand C61tiid Otmit 13 Dry clanf
EiRcsidentiat Water Supply(shared) 0 ConciettGrout 0 Dtill ckltlings�
13 Specially Gtoul 0 Gm%,vl
ppty wolf.. 0 Bentonile Slug 0 Other(explain under 7j)
ON16ftitatioe Ogecovely
X For eacbmaterialselected above,proOde amount of-tuatefialsp-sed:
041ift'i Re'ch2rge MGMiubdit-Atcr Rentutiation
Bentonite. :150lb Wtr:gal.
OAildifet Tea Dwinage
OExpeiitnenial TecljrAoLN Cbtml 7r,Pro,#idL a NW;,d6cription of the aNindannaent procedure:
06cothennal(Closed.Loop) 07ffacer
Removed DPT Tooling and :abandoned boring with hydrated
DGeothennal 00ther(explain Under 7g)
bentonite chips.
41,Datcwck(s),ahandoned, 06/25/2022
5a.Well lacation.,
Former Cotton Mill Square Site
S.Ccrtlitrattartt: [ANOVSOG
ract1hy JDN(irijpOlicuibtc)
801 Merritt Drive Greensboro, NC 27407 Briah EWin 8/10/2022
Physical-Addmss.,City-,and Zip ft- W-
41 1
Guilford 13)�.vephjg thisfibriij, I fremby cerdfy that the wellfs)was prow)aheriAgned in
Comity Parcd Ick-nlikiManNo.(PINj a6wr&Vice with Ri4AACAC 62e.61 00,or 2C.0200 SYOwkjr*
and that a copy offixis remird Ina b;ev'i prmided to lire well c I rwner,
5b.UAW&and longitude in degreestmirtlites/smnds or dbomil degrem
( *0106td,otid 1.10*olt issumadit) 9.Site.diagram oradditional Rvfl deafts:
You may use the barbs of(his page to PW046addidonafwell site details of well
IR —'*V ababdoyinteol de'Wis. You inay"attach add-itioi'ldlpa'gesif'iwxessarv.,
CONSTRUCV16N DETAILS OF'WE1,149)BLING AgAifOONED INSTRUCTIDrtiS
Atkxk%Wl rattwtefian reroord(�O'i(rjvw&Ak, Rii-Araltiple-iiijectim 6r iion-,Hvier wqVN
wells ONLY with 11m xame mflmyll ojwfimn
Ica. For.All Wells: Submit this ftwin tithin 10 dM r,of completion of%%-cll
6g.Well ED#-.CAT-43 Obandatimcni to the fallowing
Divi4ion of Water Rmurces,InformatiowprocesSine Unit,
6b.Tatalsstildepth: 77 —00 W11 Abil Sci-Vice Center,Ralcio,AC 276994617
10b,FArJtjcr#grt-ffdh: In addition to sendingthe,form Jo the addivss,in.14a
6e,Borehole diameter.6 above.also submit one tops of this!brat witkin.30 days of completion of mall(ln) abAnd6nmetd to the 1Wl13jV111g--
Dhision ofWater Resources,Underground Injection Control Program,
6d.Water level hdaw ground so rface, —00 1636 Mail Smice Center,Raleigh.St 276"4 636
6c.Outer co.Ong fen if knowr)- —Vti loc.Fjr 5:pjM gliMly fi LubgLl Walla: in addition to sending(be fonn to
the address(es),above. also submit;one Copy of this fomi withifi .10 days of
coniptelion of umql abandonme-nt g,o the county hchith department of the County
6f,Itmercasinonbing length(if limawn): (ft.) ANh=abandomd,
6Fg.Served length(if known).
Fona MI-10 Nottli Carotim Deparinicud of Environment and Natural Rewaucs-DJti,Won of Water Rcsowms Revised Ai%"N13

I
NVELL ABANDONMENT_RECORD For lr4c mti lfes ONLY:
This form call be used for single ar midh be wdis
1.Well Contractor Information. WELL ABANI)ONIVIENT Dt:TA1L.S
Brian Ewing 71.Number of tAiAls behig ahandoned: 1
lVtArFa eadgr1�28T(rwelto%ncrPC.n�tl _tlsandsinln;well onhis 1'ar midtole t!tedton ar mm-vht+ei' sappy wofls ONLY with .1Aw mie
eovzstlttr-Iz[�t,$n!rnttahvirrrzevif,w.n cxur mefvar7t r,Gz;*jFirzn(
F
4240-B 7b.Aryirrnximate volume of Water'remaining in (gap
i4t Well Cbriragor Ctriifilctltion Nmnbcr k '
SAEDACCO Inc FOR WA'I FOUI PPI.MELES�11 1,V-
caaPart±' 7e.TiVe of disinfectant used:
2.Well Construction Permit#:
Litt'lrffiwifimhlewellEcrnri&{t.a_Coarth"Sr M,Parttft-e,Inferi'tnrr,&to.,t t0miwro id Amount of disi:gftaetant used;
3.Well use(eheek reel)use):
Water Supphy Weil: 7e:Sealing materlal-1;used(06t All that apply):
l7A rtlttttal ❑lv4rtnieipalfitablEc. GI Neai CcOe t<Cat it 6I Bcmonitc Chips or Pcll6fs
OGeothcmult(llcatine, Cooli-n Supoly) 1311csidendal%Vatcs Supply'(sineia) C3 Said Cement Groat ❑Dry CL}t
❑Indn5triatlCainrrtctcanl ❑11c6clential%Vatet Suppl}'tshatcd) ❑C-budele Grout ❑Drill Cuttings
01rdeatiou b specialty Grunt ❑Geakll
Nun-Watcr D17'Wen; ®Bentonite Slurry ®Chher(cxTla under 7j)
pMattitorirt. oRer:oVely
irrjeoian Wen: for each tsjaFCYial selected above,pr+ti�ide.arnnnntof tntlteaials ed:
❑Aquifef'RecbarV. ®GmiiiaAwaler Retaediation
dActurfcr StOfuge ui><i Raxin'en t7Salitaty Barnler
❑ iljnifei Teat ❑Slonnii'ater Dmirk4ge Sentoni to.:1501b ,Wtr:gal.
❑F.xperiirtcntal Teehv,64og ❑Sulasideitce iJtitttc rl
7g.,PiOvidc a brief description of the abandonment lyroo Inc:
DGtmlhennal(Closed Loop) O Tracer
Removed DPT Tooling and 'abandoned boring with hydrated
Meothertnal fiiea ti ti Return) OOther{ tainunder 7 )
� r—y 9�
bentonite chips. e l a e s '
4.Dattjtirtl(s).uhunri0uerl: 06/25/2022
5a.Wen location:
Former Cotton Mill Square Site DV1' /60'C-
Fatilhyf O ti•rrvr Nitr>c Fachit),tl)N(trapplimblc) 8'Ccl iill�.ntioi+:
801 Merritt Drive Greensboro, NC 27407 Brian EWom ' 8/10/2022
P1tj sicil Addms:cite,'arid Zip gc qi,m tir C*h1re1 l(4 'Aft W1 I «il--nVWr b-90
Guilford f3).'fifflzing this for'nr.-I.hemhy certfy that the irclifs)wcq(trey+.+)afiemdoned he
Goativ NTM ldcniitica"tirntNo.(Pill tz"rrldnee 1611Ir ISA XC.AC Q1G,01010.u),X-7.0200 Well C'ohairttctfrn 5kritn:Yirds
and that accztat a
f0ils rvwrd hm btEv@ provided-to dhewell onwiaer.
5b.L alitude and Inngit0de in tl%ww''1minittcs1wwnds or diximt l degrees:
(iflvdl f clid,eltc L;tilkutg issriri6Ctx) 9.Site.diagramlor a"Itionaineil.details:
S'ou inay use dit bacK pf this page to providee-addiitional Atell site details or Well
tV W aibandoiarteru de'taits. You may also allach a"tiondi pages if necessary.
C ONs"CR11mbN iwTAils 01:WFLL(5l BEING ABANDONkl) SURAT!"TTAL iNSTRQCTfdi�iS
itirati4 cld cr rzKinrctrua trcvrdlsz I{®Gutfuhtz Far•ftwhipLe;*Coffin�r iti4m n uelr supnh'
rrrllsONLY frith law sr7am.camtrrnrrlom�hnt tkurrzer.r, am cvro,srrLtttrfi!art ti»tn.' 10a. For-All Wells: Submit this firm within 30 days of completion of well
6a.Well ID#.CAT-44 abandonment to the fallowing:
Diy'iaion of Water R"urres,Information P"racessing Unit,
Gb.Totffit rtril depth: 77 (ft,) 1417 Alai)fs .vice Cents ,RaldA,NC 216 46t7
lob.For Ln lW1QAA''lc: h)addltiotl to sending the tarot to the:address in 10a
Re Borehole diameter.6 aboVe.-also subutit.one bopj'of this form withitl 30 day%of Completion of'«rll
{in.) abandonment to the follotring:
Piston of
W Mail �i3adetgr4und Injection Conlsol Program,
6d,Water Ics'el helaw ground surface. tft) A cuter,Raleigh,SC 27691-16M
6c.:Outer cmpng lenoh(if known): ddressees(R) lice a above. atso submit faun within
Mile 1Inadditadditiont0 sending,(be form 10
2 it bne`copy of this fa within 10 days of
mtctian;of well abandonnernl ca to the county health department of the couw,
6L Innercasincftubing length(£hnown): (ft.)
Where abvndoncd.
6F,Stre+eaa length(i£ltatowtl):
Fomr Off-30 North CamUm Dep3nine.rd of Emtirunment and Natural Resources-Division of Water Paonmes RMscd AtrVsa 2Y?t3