Guilford_Well Abandonment_20220818 (8)

WELL ABANDONMENT RECORD For Irden!Um ONLY:
This fohn can be used f6r single or midtift wells
1.W01 CiintraMr Infonnation. MILL ABANDONMENT DETAMS
I -
Brian Ewing_ 7a.Number of wells being aloandailed: 1
%N1d1'C*M3c10rNMmc(oluttl 64 fin woo on M. ffildtiple ffVtorml or ftowwtrfer sipply brells ONLY Willi MW role
4240-B
7b.Apprvitirnotemilunti:of water svirlauting in Avn(sp* (911114
SAEDACCO Inc FOR WATER SUPPLYAVELLS t P31Y-.
G61lVa:*Y Name 7c.TiVe of disinfectant used:
2AVd1 Construction Permit 4.,,
7d.Amount of disiftfectitut used.
3.Weil ok-(6eck well use):
Water Supply Well: le,Scaling mptcyihMls used1climl,Oil That 21101y):
[7hAmricippmib6z Q.Ncw C-cmcn(;Grm 11 0CUtollitC Chips or Pellets
13CWhernst(44ca6ugCooti-n-Supply) 01kcsidmHal Water Supp4-(sineJq) 0 Sand Centrid Grout 13 Dry CLky
011udut(Fial/Conartcrcial EIRCIMentiat Water Supply(sllvw) ii Concrete Gme 0 Drill cuitiog�
ElIrrigation 0 Specially GiPLA E3 Gravel
Non-watcr Supply WCH., 0 Bentonite Slurry 0,0(kr(explain under 7g)
0M6URatinge
lnJoctio"Well: X For eachwaterial scicdcd aboiwamountprosidamount of ma Aterial-s used:
OA4UMiftch2rge
OA4nifet Slotuge and Recovey Ii!Winily Bardet
Bentonite. :150lb Wtr:gal
DMfiifeir Tftt DMirkige
O&Vditnental Technotogy PSubsideme Control 7p Provide a lieWAvicription of the abAndooment procedure:
06eo(hemial(Closed Loop) OTmcer
06cothernial(HeatJqglCbob!MRe1urn) 00thcriMlain under ZS) Removed DPT Tooling and abandoned boring with hydrated
bentonite chips.
06/25/2022
5a.Well blication: AIJ=
Former Cotton Mill Square Site
UnY',
raci14yX m*r*rNuc raFacilityFacility1DO ON P06=1610
r Lid;801 Merritt Drive Greensboro, NC 27407 Brian Emn 8/10/2022
Pikysical Aftcs.City.mid Zip bale
Guilford ]J),-.vignhjg thisfinwi, I hereby cerP�Mal the wellfq)was(were)abandoned in
coullky Pamil IdeinifficitimiWo,(PIN) ii"rdance wilh 1114-AICAC 62C.01 1 QO ,r 2C.0200!`NIIQ'hstivetfoii Aiiwkwds
turd that a cop),offids remrd has&!VP prmided to the well mner.
56.Latitude and longitude in diegmestmInutal9mrids or dedmil degrem.,
(ifuell rield,(tue tIA-mg is sloleteCA)
9.Site dingrarn,or additionaNa'detafts:
You may use d*back,of this Nget to provide additional ueff site details or%-ell
--.'*V abandonment details. You May also attach additional pages if necessan'.
CONSTRUCTION METAIIS OF WEIIL51 IletNt.ABANDONED SURUMAL INSTRUCTIONS
Aftra*%Wl cv reriruerkire wrokft)t(avalla,4k. ,Flit MR/alike ive'diart io-Minouxuw shlji6'
104ii For All Submit this funn %tithin 30 days of completion of-well
69.Well ED#-CAT-4 abinx1onmcrit
Division of Water Rm'urm,•Inf(irmati(pn-pr(iqsiing Unit.
61P.Total well depth: 57 —(f0 1617 Mail Sertice C enttf,Ralftifi,NC 2716"-1617
Kill.
M For Micalon MAI : bl_add(lipil 16 settling die f6mi.to the address to 16a
above_also subfitit oue WM,of this form cvithin 30 d*,s of comptetion of troll
fir-Borehole diameter,6 d abandonment to the folloNving:
Dhiston Of Water Resouries,"Underground Injection Control Program.
6d.Water level helms ground surface: 1636 atall$micc Ccriter,RalcH,i.NC 27094636
10c.Fur ff=�ffgggly& Lnjaj�t Wells; In addition to Sending the forth to
6c�Outer calving leno(it known): —(fL) the address(es) above. also submit one cm, of this forl %iifllirl M days of
coropilction of well shmdonnient to the oniony health department of the county
6f,Inner caiingknloing length(of known): (ft.) where abrandoncd,
ft Screen length(if lmowo)4
FairuGAI-30 Northtarotina Deparnmra afEmvirorunent and Niliuml Resources-Division oMitcritmitim Revised Ai%usl-VL5

i
WELL_ABAND_UNT I NT_RECORD Forltnet+t:tl„ �,�,LY: f
This forum can be used for singie"or"tlndtipte wdlt
1.Well Contractor Information: %TFLL ABANDONMENT DIET&
Brian Ewing 7L Number of wells Being abandoaied: 1
�VclfCfltruadorA'amrciar cllu rcrpc inrtl}nita nQweil.ontdsLl>CrFrapcnyl For trwhipM trYWYtskn a• arras-miter SI(PPN wells ONLY wills Pt& Mole
rerrkntrctera.4vl!n.Nkur�urru.11`aNClAr•s<ulv!NtawRfrann
r
4240-B i
NC WC11 Cati1iectorCdt1i0c Hon Number 7b.Apprtrzim2te rolume of Crater i'einsininfi in rw°ell(k ( 1)
SAEDACCO Inc FOR WATER SUPPLY 1sVFLLS ONLY:
CattpanyName 7e Type of disinfectant aged:
2.Well Construction Pert# .
Lt#t adl4vt&.aihte 401teriviii a e Coaa&,Swko.Variuxie,hykk oov,ei t t0itowto 7d.Amount of d3st.nfouttut used:
3.Wet1 uik-(chedcrrell use):
Water Suppy Wd 7r-Scaliri natorials used(chocl,all fim apply),
0Acric111rural t?ivltmicapolft'trttf Q Ncat Cement-Grtart tit Scutonitc Chips of Pcllcts
t7("letttltcnnal(14catingICooting Supply) ❑ttcsidentint Water Supply(single) ❑ Sane)Cenwid Grout ❑Dry May
01ndustrial/Commercial 011ssidential WatcrSupply(shared) ❑Csncrete'Gioul ❑ Drill Cuttings
❑Irri °tiotm 13 Speodity Grout ❑ Gravel
sawn=Watcr;SPppty W¢II 0 Bentonite Slurry 0 Other'(explaln under 7g)
❑Mtinttc►rir� ❑Recottiy
Injection Welt: X For each roaterial m,leeted aboE c,provide amount of'-ater•ials used:
❑AquiferRccharge, WGrg'u dtiaterRentediaaion
❑Aquifer Storage and Recnrlety t75ridrity Bsiiier
OAgniferTea ❑S16mri vAtet Dr"-loage Bentonite. :1501b ,Wtr:gal.
❑Fxps-iintental Technotoky pSubsidence Control 7g,Provides hfW'deseription of this abandonment pilw6dure:
OGeotltennal(Closed J.,00p) OTtacer
Removed DPT Tooling and abandoned boring with hydrated
❑Geothertual(fieati Li 'Return) ©Other(explain lairs under 7 )
bentonite chips. ' r ? t
i.Datewell(s).abandoned. 06/25/2022
y
;L Well location: —
Former Cotton Mill Square Site
ratiluit•�Cki•ner Nitrt>c I•acility 1Jls�r'ppplctiblc) $.CeMificsilioit: ���:��='�
601 Merritt Drive Greensboro NC 27407 B ri a rk Ewi n. 8/10/2022
Ph}'sical'Adthass.Cily,srid ZipSigiglvir aP Ct i� t7�V�11(`pigrlClar rr 7;tl�ve�r Date
Guilford 1�1-,sigrabtg this fiami, 1 hembe -certlfythal the wellfs)was(reewei aheuifoned in
Caittnt• Pamd ldcolitlaitio Wo.(PIN) atu t,rxhintc ivtth I5A A�CAC 62C.0100.or 2C.0201i(fell"{'zlhsrntcttr+.ri.SYratarir+rr/s
and firer"a cope,o•dris ravrd hos 6&vr prrotided-to the well mugger:
th,Ladiindeand long i#frdc in degreestentnutcs/seconds or db0mald:egrecs:
(lf«clt drd cute L100tis tsc") 9.Site diagram or additional Rill detafls:
You clay use the back of"this page to'pro►•ide additiomal%cell Site deMi15,OF Well
N W abaandonmeni details. You may also`atlach additional pages if necessary.
CO1tiSTR11C'I'ION D1 T'AUS OF WELLW5 BANG ABANDONEM SUBIITITTAL INSTRUCTIONS
rttiwslr a!rell crirzvdrav:tMN rerurll�zl tf avdtdishde, :Fvir iiriiityaf�iJlfCcrletre rir iKiro'xYNaY'.tirplilt
nrftxllaVLY uitn al!e eruirc"cnirrt rioic oha!inrunrarvat, +n rnn h�iurerr ra /*mn_ 10a. For All'%VL4s Submit tliis Minim ititbin 30 days of completion of urll
69.Well IDII:CAT-5
ab7nndonmcni to the following:
Division of Water RMlirces,IuforrnationTree"ring Unit,
66.Total well depth: 62 (ft,) 1617 Mail Scs%rice Center,Rated+ NC 276"-1617
10b.Fur Inlc tl n Wets: In addition to sending tbi forte to the addnss in 16a
6c Borehole diameter-6 �n,� atbow,also subtrtit.one cM,of this fb�n uithio 36'days 4 completion of ue11
abandonmcto to the following:
DiAs(on of Water Resources,Underground Injection Contrml Program,
lid tYatcr Icic1 heltrx ground sttrfacc; (ft) 1636 tltril Smicc Ccnfer,Raleigh,NC 276904636
sin Icn d lmim o)' (ft l 10c.polo YD"L idols A Injection Wells; In additiolrto sending the form to
6a fluter ca
>~ �( the addresses) above. also submit one copy of this form A01bin 30 days of
comptailm of well abandonment to ttie eotuny health de aartntctd of the county
wlicrr tibaridoucd.
6f.Inner easineoulring length(if tmoivu): (ft.)
6p,Serim length(if knowky (ft.)
Form GA'-30 North Carotim Dcpar nxm afEnvironmcnt and Natural ftemoices-DhIsian or Water kmimles Revised Attgtisi 22013

6
4'VELL ABANDflNXIENT RECORD For lrtcmalltscONLY:
This form on be used far single or mtdtipte wells
1.Well Contractor lnforrnation: WELL ABANDONMENT DETAILS
Brian Ewing 72.Number of wells being ahaniloned: 1
%Vcll'Conanclor N2mc ior%vell owner Itctsonatti ab+onAnnin;wt11 on bitirrpropeny? For futdo k klletwcxr or notAl ier svpph, welds ONLY wtrh 1W smie
cm4vmcflrMl47har/l Anwjmt,�wiv c7mynitmOt tme farm,
4240-B
NC Wc111bntr5ctOr t�rtiftcalion Nmrdt+tr 7b.AppmArmitewhime of water iatrnaining in wtll(s) (99t.)
SAEDACCO Inc FOR WATER SUPPLY NVELFS ONLY:
canrgunyName 7e.Type of disinfectant tied:
2.Wd1 Censtr action Pc mtt#;
Lt th+�7,vy rt riole rurlllcrrrr;Px¢':et ovrnJ+,$rule,J�r;a;nme.Lr}ecf;nn,err F PJkmrwn 7r1,Amount of disinittxtttut used:
3.Well tt tr(shed:Well use):
Water Supply Well: 7c.Scaling matcri-ats used(chid;till that apply)
i]Aericulturat [7laAtmicip tUlhtbtio 0 Ncat.CcinctauGrout tll t3crilonitc Chips orPcilcts
❑Ccothcmutt(1-1catingtt oolinr Supply) pRcsicicntial%Vmrr Supply(single) ❑ Sand Cenkfil Omit ❑Dry Clay
❑Industrial/CFtnmcrcial 09cui'dentint 1VatciSupply(sharcd) ❑Concrete Grout ❑ Ddll'Cu tiqgs:
131rigation ❑ Specially Groot ❑ Gravel
Noo"ikir Su p1+t7•Well; 0 Berdortite Slurry ®Other(explain under 7g)
❑Manitoling ❑Reeoveq,
1"njoctian We-it: X For cacb material selected above,provide amount of rnateriats tlaed:
❑Aquifer Recharge. BGround%vaterltenie iatitnr
❑Aquifer Slottt_ft 01A RtM'fly oWianty l3airier
OAquiferTta 17S1oriintverDrarinak2 Bentonite.:1501b ,Wtr:qal.
DEaperiutental Technology pStbsidejxe Cotdml 7p Provide a htiddescription of the ahandonment prircodure:
Meothennal(Closedl.00p) OTracer
Removed DPT Tooling and abandoned boring with hydrated
CGeothermal(Hwtj lit Return) ❑Othcr(explain under7 )
bentonite chips.
3.Datcvi'c-1(s).ahantioncd:
06/25/2022
51L Well hrcarion: AUG IS !
Former Cotton Mill Square Site ^� -' � .v . Unit
S.Certification: n 3
FatleiyrC�r>s;r Name Facility 17,tS(trpP(iwblci
801 Merritt Drive Greensboro, NC 27407 Brian Ewif 1 8/10/2022
Physical Address.City,and gig
Guilford 13) fiVdr{g this- bmr.-1 hereby cefHly that the wellfsj was(were)ahtVidoned is
commy Parcel Idcnt➢fic rtimiNo.(PINT trt4at)rdanve with I5A XCvAiC 42C 0100 or 2C.+7200 We11 Consmtrwon Skahrkwds
and that a cop,of dris rvmrd hm-bear prop 4ded to dre well orsrarr,
5h.Witudc and longitsr in degrmlintruitcii1scean4s,or decimal degrecsi
(if wen nee,core L•rtt6ngtssitftttera) 9.Site diagrarnlor additiona-still detat[s:
You may use the bad-;of this piigc to provide addidOnat well site details or nll
abandanuteat detaits. You may At o attach additionaf pages if necessary.
CONMUCTION DETAII:S OF WELL(5)BEING ABANDONgD SUB11iiTfAL TNSTRUMOlYS
hftht;4 e�r1l errzvtrrtcrt+Jn rocnid(s%'ii tivreilrsM1lr. :Frio•mukipk ih}rcrir5n titr r�mn•treiv'.tail,rih
+nebx OaVlt'+ru4 nc�a+raar ear sr tiox obnixtorrmrriR SOH+inn arlvrcr r� run_ 10a. For All Weds- Submit ihis farm itithin 30 days of completion of%%rll
6a.Well ED9:CAT-6
abandonracnt to'thc following:
Division of Water Rekourets,Inforu ation-Pr6maing Unit,
6b.Total stela depth: 62 (n,) 16I7 Atmil Service Ceinter,Ralcidfi,NC 27699-160
10b.Fur 1 leslion W-&4 s: In addition to sending the forltr to the address.in 10a
6c Roreh0le diameter.6 (irl.) above_also subinit.otie cops of this brit►within'30'days of•completion of tt�ell
abandoont rul to the folio ing.
rd.Water level below ground surfaeci (ft.) Dildsion r of Water Resources,]Underground Injection Conlon Program.
1636-Stall.Service C'cnter,Raleigly NC 2 7 609-1 636
6e Outer Casing length(if known): (fi, loc.For Rrater.5trnnly Rc iniertinn Wells: its addition to schding the form to
the address(es) above. also submit!one'copy of this fonts ,,within 30 days of
completion of well abandonnuot ito'Ac county health department of the county
6f.Inner wsinr,:/tnbint;length(if known): ..(it) v+jcm abandoned,
6g.Screen, length(if kno t): (ft.)
Form G1V-70 Nonh'Carolim Depanrncra of Environment rand Natural Resoruces—Division of Water koortrces Revised ArtVjs1 20 B

i
AVELL ABANDONMENT RECORD FoTIrderml w'ON,Y; i
This form can be used f6c single ormuitipte we0s
1.Wcll Cantractnr Information: WELL ARANDQNMETNT DETAIiLS
i
Brian Ewing Its.Number of wdis beifig a andon)ed: 1 __
%VdtC©Meacrm°Name Wvve-llawfler[ximrui7yalis nina Nfll on hisAterploPerk l Fcw andrip le kllen'ton rv' sirpph' veft 0AILY wNi :tAw €raoie
aeNiSrrrrcbmt,$rbrurrltrirrnanr,)YIn ciar.�Mtrtf rxiafnmi,
4240-B
7b.Approxitnate wdunw of rt•attr e'er wining in
NC MI-A(.1oiindorCtrlifn311i+ziiNant era 3
SAEDACCO Inc VOR%YATFRSUPPLY1�truson :
corny iwy Name 7e.Type of disinfectant used:
2.Well Construction Permit#:
Lsrtr!l fkaaRlaue!la:ririlta(�.< C"ir¢trhtStriti,T'rirtr ti,Lryeccfinrr.Hh_tPjk.mwn 7XAmottnIordistAfectiiutused:
3.Well urge(eliukwell a )
Water Supple Weil: 7c.Scaling materials used(chock Oil that appl}'):
i7Ae;rkidtrtrrt EjMonicapttM1bljC- 0 Nett Ccmcnt:Grant to 0cr?tonilc Chips or Pt lists
Mmolhennol(llcatingg Coofina Supply) 13kesideritipl Water Supply(sinelc) ❑Said Ctinenl Grout ❑Dry Chtyf
❑indusfnaldGoratncn i rl Dltesidential Water Supply(shatad) ❑Colie me Grout 13 Drill C"ings
Olrti tioit 0 Spe0alty Groat ❑ Ora,v l
Non-Watcr Supply%ell; ®Bentonite Slurry d Other(exTla n tinder 7g)
OMe titoring 13 teto+ety
injection WC11: 7f For each material soletted abmt,pruside arrionat of rnateriais used;
0Ag1"e kcch3rge, MGrtiiudri:tter R ntEdiiitiiitt
t7A4 t Sion tot and Recov ty bSAitrity Banner
OAgnif Ttxi� US1DtittilliterDtii[l Le Bentonite. :1501b ,Wtr:gal.
❑F_tpeaitnental Tetltnoiogt+ DStAtsicttnct Cbttiml 7g.Provide a brief description of the aGytolohnient prtmethire.
tGeothennal(Closed Loop) 07fracer
Removed DPT Tooling and abandoned boring with hydrated
t7Geothermal_(Heatl oiin Return) 0Otber.(explain under7 )
bentonite chips. ;�-_�,<�--�-p, P .-�
4.Oat+Vrt11(s)anlnd�ncd: 06/25/2022 +�� s ,.5 ? tl _ -
Sa.WCH hX11110n:
Former Cotton Mill Square Site lDtt; ,B .t �� _ Unit
FacililrOwnbrNnme Facimy.rtm(ra©pliviblci S.Cerllflcatioit: DV.Q.30V
801 Merritt Drive Greensboro, NC 27407 Brian E i n 8/10/2022
Pit}•sira'Aftes.City,acid Zip Dale
Guilford Lb.-signing this)bmi, I hereby certifp,that the mellf7)wpx(trerg)abemdoned in
Cotn>iy Puma)kkmifk;al4rntNo.(Pl Nj of vrrlemee ivit r/JV N AC 62C.010t)ttr.-247.0200 9-Wl(kuralittclioti S4o"ekirids
and that a copy of'tiris record hu-r b evr pr mickd to 11re well awner.
Sb.I..atitude and longitude inr) cndminuteslsectarrdsordeirnald:tgrecs.
(Swell 661d,htte Lrr#krttg tr tltipieryl) 9.Site diagram or additional,%adetails:
You.n.a)"use tlk back,of this page to pfbvide additional well site detaits or kvll
i< W abandonment details. You may aiso;artach additionat pges if oecenary.
CONSTIHIC'hON DETAILS OF WEL AJ5 IIEtNG AR.ANDONED SUiIRtf7TAL i ,TRUCTIONS
rtfi'ctth�xrdt rnrtvli'uNtkire rucTrt!/arp p}'t+v'bf✓<r�M1.4t .Peer nrulfifitr,in}rcfdtari:rir'miia.titin4v'.wtyalt
>„eltxOXLY ovA ilm&mte s inrrioit'r airctiunri ir, oo run wWfirrm_ 10a. For All Wig v ,Submit this;fair, midi, 30 du}•s of cdtnp dtiiin of well
6a.Well®g+CAT-7 abandonment to the followlrtg;
Divisian of Water Resourm,InforinatitlnProetssing Unit,
6b.Total will depth: 62
1617 Abil Semite Cimter,Raleio,NC 276594617
(ft.)
1011.ftr : let t on We is: In addition to sending tho form to the address In IN
6c,Borehole diameter.6 (yn y above..also stibinit.one tx�pti of tiles fbibi iAdiitt 30 days of completion of null
abt ddiinmcrd to the follo-wing:
6d.Water'level below•ground surface; ffio 1636 Mail Sense C[iidergrouad INJoctlapControl
-16'36 lFiogram.
1Dhision of WakT Resources,i
ctttcr,ltale`r„ly lr'�2769'J-]636
the add s a Iukxtinn:Wells: in addition to sending the form to
6t.fluter casing length'(if known): (ft) t otm copy of this fore, Asithin U, 4' s of
eornliklion of mail abandonment 16 the entmty health tlt Pa tnicul of the county
bf.lnaa`r arse,+„/tnitina t-ngth(if GitOriu): (ft.)
,%It=abandoned.
ft Serm length(if 1®row°n): (ft.) I
FornrGAI-30 Nanh CamHea Delimni:ril of Endroament aid Natural Resoirecs-Division of WaterRcwwoes Revised August-V t3