Guilford_Well Abandonment_20220818 (9)

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WELL_ABANDONMENT RECORD FaT Intermit Us ONLY;
This form can be used for single o:r.multipbe wails i
I,Well ecintradar Inforination: WELL ABANDOJNME{T DETAtf
Brian Ewing7a.NnriiiterDitYallthCiti};8hantlbaCYl 1
WeirCoutracip-N-Ante iweiilfown r p_ uiatl oo histher progicn}) Frw widople k![ed'tcvi a mrfmi)16o sIppN welts- ONLY willo t1m revne
ema�mrcticwa,trtrurriYram�enf,)rie cmrawlaaf�t��fprnr.
4240-B
NCNt°cil ConlrlaorCenifirntimMnaber
7b.AppnvAnuite volume of watar rt inaining in ir'ell(it)
SAEDACCO Inc FOR WATER SUPPLV WFLI:S ONLY-
CIUPVaV%'Narsac 7e T%pc of disinfectant used:
2.Weil Construction Perr It 411:,
L*w all rrlpll vAle wall}email&(it(itL C4orgv,uWij �rkmrwro 7d.Amount of dis3 of first and
3.Well use(cheek wtH use):
Water Sir pply Wcdl: used(choct all that apply):
OA*q;ltoril bmiinicipai/Foiic. G Ncai COMM,Grout 51 ftntonilc Chips or Pt,llets
00coahermal(4cotineCo7ling Supply) ❑Residential Waicr Supply(:srn)e) ❑ Sand Cetneid Grmit ❑Dry 04!v
❑Industrial/Cnmmcn:aal ❑Rc�idcnti it Water Supply(shared) ❑Concrete Groul ❑ Drill Cutting,
t7htri tionr ❑ Spoalty Groat 13 Gravel
tiara-��latcr Supply Well 0 Bentortite Slurry 0,Oft r(expla"In under 7S)
0motdtodng, ❑Reco-ttly
tujcction Welt: X For cacti tiiaterial sheeted above,prostde amount of m Aterialsilsed:
❑Ajuifiei Rccbar#e. ®Gnivaialwiter}(eiadliiidoir
oAtluifer Storage an'd Ricmay OSalWN,Barrier
❑AtltrifdTest ❑SiCiittritatcr[)reirtitge Bentonite.:150lb ,Wtr:gal.
OExperintental Teehnotog pStrt+sidetre Cbtdml 7r:Providt a hriii docription of the abandonment procedure:
1:1Geolhemctl(Closed Loop) Cl7r3cer
Removed DPT Tooling and abandoned boring with hydrated
OGeothertttal(t3eati tCaoli Retum) ClOther(ex laisntinder7 ) ; _ - p.—
bentonite chips.
6.n
4-Datow4lWatiandoncd: 06/25/2022
5a.YVell location: 1f�cdai�.r�:c n r,- •-,k;��� l ln>l
Former Cotton Mill Square Site
Fatiliq •r�rNrsrrsc Tatilty tAd(aFilpplciblel �•Ccrtlficatlta;r:
801 Merritt Drive Greensboro, NC 27407 B nar Ewi n 8/10/2022
Physical Address.City,mid Zip $ eratatcc r,f c. Air WcrI CA i1w r;r r.•Al olva-e D;qe
Guilford Bi-signtng this farm,I Gerehy certify thm the weiles) was(w iv)ahtmdbned hi
Coal* Paved ldentit6c iimt No.(PIN) i,&xa r tatace walr/M YCAC 02C.10100 or 2C.0200 lF'e11 C ftgr tte uon Sastx*irrts
mad than a coptr o,f this rewrd los bee-irprr ided la the well order,
fjftLatitude
l r�dde*a Ldt�n�ig�r eleVA) rnfptrteglSep?nal5 Or di3cininl dr rree5 ry Site diagram or;Additional welfdccxfts:
You t q.use tip back:of this 00 to Provide Wditional well site details or ntll
A' W abandonment details: You may also attach a tional:pages if necessaq.'
CONSTRUMON DETAU S OF WRl USR).Itt1N6 AB.W)ONkD SUBMITTAL:JNSTRUC IOATS
rttlrith m,rtl erirtrA•axtb9rt ra'Crlr[1(S/It'Uvr�ftteh�. Fail•lKutrFtlk•iljYeftrlli:ilY hrlri�N•[IYr4'Sulljlh'
welk ONLY+hair ilia Amte ytw can_arlunft;rlll ,Gram_ 10a. For All W&v. Submit this fh m tirithin 30 days of completion of ti-.rll
6a.Well LDO CAT-8 abandonment to'thc follonvin ,
Division of Water Reources,Infor matiiin Prvressing Unit,
66:Total tell depth: 67 A) Ib17 Mail SeMce Center,,RaleiAli,NC 276"=1617
10b.har Tnical_rt Wells: In addition to wending We far►tt to the address in IN
fie Borehole diameter 6 (Itr.j above,also subuiii one ,of this form t6thiu 30 d;rys of complafiott of nit:))1
abindonment to the following.
DiAiMort of Wader Resources�Underground Itijecdon Control Program.
6itL Water les-el'below ground surface- (ft•) 1636 Mail Smicc Ci:riter,Ralci*NC 216994636
Outer eosin length(if known): ( ) I0c,Fnr Water Sirtinll•lC Lni+acthrn WCIIF; In additimto sending the fort to
Gc
g �( _ the address(es) tibove. also submit bne copy of this form within 30 days of
contptetibri of Mall sibandonrrrcnt to ilic county health depa nnuerat of the ctninty
61%Innereasinoubing length(if Imown): (ft.)
wwhcrrc abandomd.
I
ft Sam length(if known): (II.)
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Form GW-30 NonhCamtim Depnna:a t of Environment and Nourat Remon es-Diviston of Witer R solder, Revised Asugrst-Vt3

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WELL.ABANDQ.NTAIENT RECORD For Ir emil Uk ONLY:
This form can be used.fQr siqe or.midtipte wells i
1.Well Contractor Infnrmatitm: BELL ARANDW01ENT DETA1l..S
Brian Ewing 7L Number of t vils being abandoned: 1
%%Iell CoivractprNow(of welt oww�I naIHy abtantcrnlno wtd on hisA&pTgEr v) Fm- ea1dopte fgje ttatt W amrt-i4`w sirp* •ratite ONLY with IN- € je
c �arrnrtkxa.hrtaadwwa�rtt pmCarrSWI.Vilm6neform,
4240-B
NC Weil GartlrraorCenifraalianNannber 7b.Apl mWinate ralume of matir[remainiog in*ell(,4y ("ga )
1
SAEDACCO Inc FORNVAT'ER 1)PPI YNVE1�LS��ONMY:
Cbarq+an}N�rrnt
7c Type of disinfectant u3ed.
2.Wd1 Construction Permit fig:, ,
lwd. letyt#&vbh ue.0 fcrtnits tile!Cualrtlt',3rirta:T6rdrusce.L drirt,_rtt ajfkmt ro 7d.Amount of disinfectant used:
3.Well use(Check tt e u e).
Water Supply Well: 7e:Sealing in tel9alss used(check all that apply);
DAerit tnitttrAl 13municipat/Pubtic ®:Ncat Umck Grout tll lamonitc Chips or POW,
❑Gcothcrrml(7lcatingCooling Supply) oPcMdratial%VateT Supply(sin)e) ❑Sand CeAlk ni GnAt ❑Dry Clay
❑in ditg1riaal/Conuncicital 1311csicient6t Water Supply(shared) ❑Concrete Gtoui ❑Drill Cuttings
❑itrti tioli ❑Specialty Grout ❑ Grm*l
hnti,"Nrakr Sttppty}Vetl; a Hentonite Slurry ❑Other(explain under 7g)
❑Moerltorine. ❑ ecowly
lnjoction Well: 7f.For each tuaterial erected abt,iet proside amount of mitetriallsased:
❑Agirifer'Recharg 06mautdiumerReut4ation
❑AquiferStopge atd Reco<`t y OS€diirity Barder
❑Arjuife Test ❑Si(rrfiriviterl)>=,iirw:e
Bentonite.:150lb ,Wtr:gal.
❑F.aprrirnental Technology ❑Stdasidettce Corttml
7g.Ptovide a brief description of the abandonment procedure.
Weochennal(CloscdLoop) ❑Tracer
Removed DPT Tooling and abandoned boring with hydrated
®Geothermal(]ieati wok Return) 00ther0: lain tinder 7 )
bentonite chips. �^c,,� �a s sum
4.Date%vii(s).abandoncd 06/25/2022
51.Weil location: h -
Former Cotton Mill Square Site 16it°ugT,,zwG1 Pm:; ,Ing Unt
FaxitiigAOn ni r Nrtmc Facility It tiEatpPliC.bli t S.Certification;
801 Merritt Drive Greensboro, NC 27407 Brian Ewan 8/10/2022
Ptr}tsical Addrem.Chy,atidZip $reFtYfrrie of esii icA Wtii Cmar�.inr.wr,r.clt Q,rctir Uaq�
Guilford ed alr{ this fibmi. I hemby cer4 thai the xefi#)wav(*ere)dfituido led he
Cnwriy Pamd identJ5644 iNo.(PIN) o"Pilance lvfdr PU XC4C 62C,010tl.ur 2C.010 Mel/ SY'ratrrle`irds
evil drat a ccpy c+J'lkis rcwrd has becvr prcmidedt'o kiln well oW1?Vr.
(,f„ell rb,tI 1,olte L1•�nsig is tp ,�ke4) /rnintitca/s nds or d± first it degrees.
9.site di use d>l b��l ut ih si pe�iletattls:
1gito. t e•Ses -
k to;pro�•ide additional sell site details or u»11
1\ �� abandonmentdetails_'Youmayatsoattachadditiotnalpages-it'necenmy.'
CONSTRUCTION DETAiiS OF WF1,14,10 BRING ABA1YDON .D SURN117rTAL INSTRUCTIONS
.runt, ,rill rmtottYr.librt rrctk?d(tt)l(aVAjlteWk. reir ihnitifrtr itdjectdr)n to t anynuaisr suytah,
,r�rr8 atvtr,�trn tlw rr2vre cruts9ltbte" nrxlwter,r. err a,�, tt ruk,i�rair. Ina. For All tycll€ .Submit this!farm Within 30 days of completion of ucll
61.Well 16#.
CAT-9 aibandonmcnt to the following:
Division of Water Resaunes,lnformatii►n Prtit;•essing Unit,
6b.Total well depth: 67 (ft.) 1617 Mail Seriice Center,Ralcel+h,NC 27610-1617
10b.For In lealon MW_ In addition to sending dre form to the addressi in I©a
6e.Itorr hole diameter,6 tln;) above_also akfitit one 66M,of tbif tbrnr uithiti 36 days of completion of troll
abandonrnertl to the foll1i'MIrg.
DiAlsion of Water Resources,Underground Injoetlon Control Program.
6d.Water level hda*ground surface; 00 1636 Stall Scnicc Center,Raleigh.NC:27699-1636
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6c Outer easing length if ImoRn) (fL) lot. For Water Sirnnl�•R Iolccth►'n«`ells; to addition to sending the form to
fi �( the address(es) above, also submit one Copy of this fotini tioithin 30 days of
completion of well sbandownent to'the county health departmcni of the county
6C Innercasing,,ftnhing length(if tmawn): at.)
6g.Street lengrlt(if Ianoirn):
Fom GW-n NonlsCaroHm Depunctt`cd of&n ironwnt mil Natural Resources-Dik-isionof WaterRcsoiates Revised Aogrsi N13