Guilford_Well Abandonment_20220818 (10)

I
WELL ABANDONMENT RECORD Fot Werml Um ONLY:
This form can be used for single ornndliple Wells
I.Wets Contractor Informations )YELL ARANIDONAIEl T DFTAIts�
I
Brian Ewing 7a.Number of wells toeing ahandanetl: 1
\Vettfntmlrrclprt�'snmiar�cltu�r�r Ran J7y_al�a�tasilnoi�rll.onhh�IterpropcAy) Fo. fratrpfe trt�ecwa,'r or ftof mkltrr stpt# wells ONLY Willi ties 4wlr
c»rkstrmtu�v,i>nttelrurrar�u,iwncarrMvitltiau;firm,
4240-B
NC Weft ComrraorCertifr uavn Number 7h.Approximate wilume of sratcw remaining in Well(x).-(pt.)
SAEDACCO Inc FOR WATER SUAPLV WELLS ONLY:
Une}+uart•Kane le.Type of disinfectant used:
2.Well Construction Permit 4..
Ltst u14faer1roy rxe Coanht Sasvc;klarldhtV.Jnfs (J1t clef lArrown 7i1 Atnotrnt ofdisi:nfmant used.
3.Well (check-Well tow):
Water Supply Well: 7c:Scaling materials Used(000;)li that apply):
OAgjFi1ctdtttrat ❑1tNtriiitipstlJPtibluc 0 Ncat Cctnetil Gttr1-it (3 Hcntvnite Chips or Pellets.
010cotheTmitt ftatine`,lt,`Iao ing Supply) ❑pcyidentinl Water Supply,(sinelc) ❑sand Cement Grout ❑Dry Ciaj'
❑IndusttiallCnmmcsiai ❑to idential Water Supp4,(shared) ❑Concrete G-131 ❑ Drill Cattingt
t7Im ation t7 Specialty Gtom ❑Graft]
Non-Water Supply Wolf: G Bentonite Slurry CI Caller(expiai rr under 7p')
0Monitoo a ❑Ft of
injection Well: 7f.For each material selected abosc provide amount off cn_atcrials used,
❑Agitifti kccharbre tBGroniidittder Rentediation
❑Aq i 6er Stonige aixl Pftn ery 109alin1t_v Bonier
Bentonite. :150lb ,Wtr:gal.
❑Ayteifet Test [7SiottnttilerlDf•:trta�e
0ExVerimev1sl Teelmology []Subsidence Control
7g.Prttvidc a(oriddcscripttoa of the ahalndnnmont procedure.
Cf6wthenm al(Closed Loop) Maw
Removed DPT Tooling and abandoned boring with hydrated
DGeothemntl(liea6 f 2olirr Return) ❑Cft-r(explain uoder.7 )
bentonite chips. y l
4.Doti:ror0fs).ahandoncd, 06/25/2022
f 5a.Well hication: v -
Former Cotton Mill Square Site lri�%i iiv"1 ?'i i•L x 4'•^ URK
Fatilug• n•rrr Nnir� Far:tlil}•tlDti(Etipplicibic)
S.Certification: D1'AeQi BOG
801 Merritt Drive Greensboro, NC 27407 _Brian Ei n 8/10/2022
Physicd Address.City,arid Zip $tVi;mhISO of t of ifiied nt,!,- :tl Chvesr t);gfi
Guilford B).•.sfpfw this fnw.1 herehy ce'rtr�,,that Ae wellfsj xvs(irev+e)dbeuidoned hr
Couuiy Pamd IdenliticailaatNo.(PIN) nci?vrddnce ivfth I SA 'CAC. 02G,fill'6 of 2C.0200 Ii;`ett•Ckinvin ion Svon&r rds
and f cal a copy e,_f this recant Im beeevo prmided to file wall owner
5h.l.tnitudeand lang1w,de in geeston#nntestsecondsordocirnal degrees:
(if"tirtl t tz1,ove L-1001tg is r ritt� ra) ?.Site diagram or additional well detalls:
You may use the ba&bf this page';lo provide additional well site details or well
N W abandomfleru details. You may atso`attach additional pages if necessaq-
CONSTRIICI'ION DETAILS OF WELLM BFING ABANDONEb suinTn TAT.INSTRUCTIONS
Awdr 11 criwar"mare "Kil.ArnhiplL tatymTe y ar W".4 cV&SUPPf1'
welk O NLY with tlw mmte exaatsv a ftuio aM1mintiArMrerit;_Iwo cow arlunit.oefimn. l9a.For All Webs: Submit dus 1&M ictithin 30 days of completion of lull
62.Well IDe•CAT-11 aboinllonmunt to the following;
Division of Water Resources,Ltfiirniati(►n F,n)cessi�Unit,
6b.Totnl well depth. 87 00 1617 Aiml Scitirice Canter,Raleigh,NC 276"46I1
ittb.Ear In.lestlon W/clls: in addition to williag the form to the address in ilia
6e Borehole diameter.6 above_also subutit:one tops of th£-horn within 30 days of completion of well
fin) abaodonmem to Cite fatlaxving:
Dhision of Water Resources,Underground Injection Control Program..
6d.Water tcsd hclfm,ground surface (ft) 1636[Nail Scr%vec Center,Raleigh,NC 27MM-1636
6e Outer cxAng length(if imown): (ft;l 10c,boor Watm Sarmty A looks-I n'h V1'eits. In addition to sending the form to
the address(es) ati0s'e. also submit;otic"c.M, of this-form Witbin days of
comptetion of well abandonment to t6 county health department of the county
6L Innercasineouliing length(if lmonn): aft.)
-di=abandoned.
I
6g.Scream lenolt(if knovm): (ft)
Form Gat'-10 Northt=Hm Dep3nmcm afEmIronmcnt and Natural Resausccs-DJ+,isian of W iterRcsoaroes Rcvned August 1Q1:3

WELL:ABANOONAIENT RECORD FaTimcmilUscCFNi:Y:
albs form eanbe used,fbr single or mulople wdis
I.Wctl ContraeforInformation: WELL ABANDONMENT DE`PAILS
Brian Ewing 71.lV011111tr Of Wells being alrandCne d: 1
warc,outmeiOrNsencfortiltowiterpermmMyatmritidriugKeUanWIt rpropcny) For mdriple trtFmfor or aw tj4vtcr sirppi vro;ls ONLY with the sduie
cov�sbvrenrxa4�ntrrar►mu��r,�r�n czar m+dv�iit;cwnfonat:
4240-B
NC WbU GQnla�gor C.�rf ifrctllmia NmnE+rr
7b.Appr timate srrlurne of water!rtmaining in well(sy (gat)
SAEDACCO inc FORWA'I'fR UPPlGV'%%1KLL",`()1�ILY:
Canvany1famc le.Type of disinfectant used:
2. Vell Construction Permit 4e
Lutti4l ref htewrlraernrlln(i.i rr1► rm4;Y"r�rtrfine.lmtNcfinrr.Nt.t. kmiwm 7i1.AntounIof distrifedautused:;
3.Well use(cheek-hell use):
Water 5uppl±;Well; 7c.scaling matt rlals used(shod,All that apply):
17A t lltml ❑1�llrrnirr ipailPr►blic Nit Ccntcvtt:Crroart. M UCnto.* Chips or P010i
❑Grnthcmwl(ltCatinglCoolinp Supply) ❑ltcsidtrir I Water Sizp'pk•(single) ❑Sam Centtle Gittut ❑Dry May
❑industrial/Commercial EIRasidenthtl Water Srappl,(shwW) ❑Cdicttte'Grout ❑brill Cuttings
t711tt do j ❑ Speriahy Gtottt o Gea-gel
Non-witcr tpty well.. 0 Bentonite 5luny 0 Qther(lain under 7g)
Elms ttltoritg, OReer►�e
Injection Weil• 71 For eachmaterialsdeetcdt1h4Ft,pi�ldcatnont�tofmaterials�rsCd;
❑Aguife►`'kecharge 043niurid4mter RentediF tin
❑Aquifer StOta_ge and Remmr ❑saiiti0i Barrier
❑ iquifei Test 17St6nmvaterDmini a Bentonite.:1501b ,Wtr:qal.
❑Facperrrnenipl Tecltncatc>gy DStibsacEetict CotNtal 7g,Provide it irrief d6cription of,fire al►sndrrnment priovedure:
i7Geothertual(Closed,Loop) ❑'Tracer
Removed DPT Tooling andabandoned boring with hydrated
❑Geotheawl(Heat li Return) 001kr(ea lain under 7 )
bentonite chips.
4.Dakwell(s).ahandpnCdt
06/25/2022
Na.Well kwation: p.iJ � 202Z
Former Cotton Mill Square Site ��, Unit
8.Certification: Ir�Lstvo�" wa �
Faciliyis7nrerNamc FacilityITae(ifBpplScahle)
601 Merritt Drive Greensboro, NC 27407 Brian E un. 8/10/2022
Ah%'si¢aJ'tLdi6cs:City.and Zip $Lecml;c al("kri ifs�g 41 tti Caner r;lo#<7T r'110 VMr DnR
Guilford B3,,..Agntr{g this Jwmi, I henmhy cerdA that the zrelfls)roars prere)abandoned hi
Col M I n County Pardenut tirniNo.{PINty actvIrjdite ruffle 15A X7C4C 62e t)1tM.ur2C.020a)W-vibCatistme adn Stanrlrr s
and that a copy ofdraa record has h.erae p mided 16 Are well owner.
5b.l4t ode and longitude indegrx lininutes/tends ordixim ldegrees;
(if-wellCeetd,tEut Lr►,llnng is sal lE}e�it) a.Site diagram or addiflonal wa detail:
You.nw),use the back of ibis page to prm;ide additional vsei1 site details or well
N W .6andonmerlt details. You tnay .:also slttaclt:tdditionai loges if rr emiy'.'
CONSTRUCTION I)FTA111.S OF WELLS)BE1Nt:ABAN'DONI.D SURNI11TAL TNSTRUCT10�iS
:rttrutr nrtl cxirttitrilxtfaet�cvrC!(sj d4'ov4ilfehth .�riY itruhi�lr rn}rcfiore sir iwtrr-�n�en�sr'3�tgch
%vAsONLV with vine saw car,suhtdi rmvA m 10a. For All W091., Submit thn farm iiithin 30 days of completion of-well
6si.Well I6#.CAT-12 abandonment to the folio wing:
Division of Water Remurces .Information Processing Unit,
1617 Mail Sci-Oce Center;Ralc'io.NC 276"4617
6b.Total svell depth: 67
IOb.For InIestlort Wells: M addition to sending the form to the address in ioa
6 above_also sold}tit.One 6MI Of(leis forirt ccithin 30 dates of completion of wl'ell
rye Borehole diameter (in.) abandounteid to the folln-ring:
rd Water tenet below grmritd surf tCC: (ft) Division of Water Resourees,tindergrmarnd Injection Coatrol.P"r6gram,
16U Mall Service iC'cntcr,Ralei_h,14076994636
6e.Outerten ri known,): (fk) loc.Ur Water Savours•:& IniecW M.Ha; 1_n addition to sending The form to
caning ( the address(es) abmwe. also submit one'cotit of this forni *itltifi " dais of
cornptetiun of-yell a6aruloruraent to the 06mily health depaTtmerd of the County
A'h=abandamd.
6f.Inner casing tubing kmgth(if known): at.)
ft Screen length(if known): (tit.)
Fom GR'-M NortlmCarolim Dep rincoi afllmlronimcm and Monist Resau-ces-Division or W'ntcr Rcsotuces Revised AiLg►ss-2V13

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NVELL ABA2aONMENT RECORD 1a.ltrielm,trrxtiNl
This form cakbe used for siugle or.tuuitip[e reps
1.Watl 6'atradIor Information: ] , LL ABAN06MWIN1'6 0PTA(S
Brian Ewing 7a.Number of wells being abando ed: 1
�ycBCCn aclorlYsir {araa cttatir rp r�n�ttly',al i unia ?cil.aa h€�li rprat►cn 1 Ho' m:irlti(aie tat00fa+r aw aaara i+atezr Sim' WOW ONLY Well tole
as+a�rtrrcter+n��'a�.av4rr�r�cmt,�ranrorr�svtvAi�t,�as,f�nat,
r
4240-B
7h.Apl►rtountt a vadunre of wash`mAining in rtell(x}; _(gal.)
t4C Wttl Gbralrugor rti lLing Nnmti>a;
SAEDACCO Inc VO W,i►TERSVPPLV}ia1?1,tSiOT4L 'S
Goraspatia)•Naiat 74L Type of disinfcetant used.
2.Well Construction Permit d:
LwdlattynPicgAt4 writparmits fiat vwfttjt Caere.V'iiradrrcc.larymirio,0'l trkmiWo X Amount ofdlsinf stout used:
3.4Ve l it9 rtchetkwe l use):
Water Supply Well le,S91ing in oil that a,rply):
G7Agrilittnral Dtulririicilxaifl'rabli : 0 Neat tcmertt Grind M Bcr4onk Chips ads Pcltctis
❑Ccothict l(14catinS0Cvo1in-Supply) Altesidentisd Water Supply,(a in)c) ❑Sdirsi Cana Grntit ❑'D�C1a�
❑hartustria lCtammerciat ❑lteaideottat waiter Su'04,(.hated) ❑Cob cle Moot ❑D iil Ciiitings
❑liti Lion ❑ Specialty Gtoid ❑ Gravel
l�tfn-N;r z u>tiy+i71" Its ❑ BentoniiteSlurry 0 4 r(exTlainunder7g)
❑Moaitttting ❑Recovery
ttj ti n Well Tf.For each material selected alica c,prioside amount of ritntcria>,;used:
❑Agitifet�cliar��. �Givoidtttaler Iteuredia�tion
limtkilet stofsl9s 110 "Way gSa1hdiV Base Bentoni to. :1501b ,Wtr:gal.
❑Anttifer Ted ❑Storamiitet tltnitWpe
❑ meirtgl Technotog Mubsidetice Cbtotl of 'P ttridc,ai'hriiI description at the abandonment procudurt:
tfGeothenritl(Closed 1.oop) ❑'Racer
Removed DPT Tooling and abandoned boring with hydrated
aGeotherrmal(Hgatine2oli2A Return) 00 tcra( "lainunder.7 )
bentonite chips. U.
_� rr
C Datc*Tz,ts).nl►anit4ned; 06/25/2022
5a.Well location: ! --
Former Cotton Mill Square Site li1uS't'+ 1 ! ' nt
1 a061i(grx ri rt+tIusae FasilGi,UM tat appticibie) S.Certllltntiorr: �','a' ,
801 Merritt Drive Greensboro, NC 27407 Brian Emirrl 8/10/2022
PItysical Addrms Cit},w d Zip 9a afG itil d :tt r`irti,t tcii r,.,'dtl thrice
Guilford 19hV vi¢aatng thls)Crrnr, 1 hemby cerfify that the w,e11 iF)"tvus(were)a7tanaraealoned iit
Caaai x° reamer l_de1000i"ti LWO,(PlNj aecx�►dahte*41h ISM ATCAC 42e•£1 .or 2C A2 Tt'a•1J:tbstrttcttoyi S ratn'A'wds
and tJrcit a eb,av of this recard Jm bi en prm4ded In tyre well owner,
W t;atitude and longitude in nds or deeimnl degrees:
(-..ml A'Od,trace L•ata'irvaa2 is sit i ieri) 9.Site diagram,or ad+Litionai well details:
You_nig use ilk back:of"oge;to primide a"fioual wall site details or n01
N W aba. ydotrmeat ileWl>x. Yon tray ask Aiacl a"iion pages"it necessary
f t�14 T1tUCTIfyt AWTAI1S O Yl+'P UE NG
—ABANDONt,D sUMMAL IrNMcrCTIOly�
:ifira&i4 srrtt rnrzrt,'amtt+are ta•c'rartt{xJ'd{filba�ehta! .�rir arcuttda�t "rarjrci`tr)r`i.irr"mm�n-uv�v �,
nti?fta taVLY ri•itA idav atuarr"cr�+rat tear•r currha rrramar.� n cnro rrlumlt;ria�r ire Mat. For All Wr`11s: &bmit tliis;Faun+,,Mthin 30 di Ws of conipletion of r►rll
Est.Will tDp'CAT-13 ab'itsdonrnciatto tbC fallqitiiig:
D1r'Idioa ref►teeter tt iiraes,i>itrir�oti{ru Pt rcrssin Unit
6h.Total ssril depth: 62 (ft,) 1617 mail Novice 6Atcr,Raleigh,NC 27699=160
10b.For Inledlon 1t' s: In addi6,n to sending dreformn to tree address in IN
ficY Borehole dlamcter:6 (ill.) above,abo subahit ooe o�pvF of ilis tortri void n 10 days apt comptttion of tsrll
abandonmeot to the folinti•it%,
6d Water le«!hctritr :rniind irrirfacr a ) Dhlsion.of Water Resources„1Cindergroudd bjecdon CortlriA Program,
163E Mail Scn•icc Ccnfcr,ttaleigh,N(!276914M
6r-Outer easingif ({�.) W-Fni:H. t�er.�lrrrnivA lnlecttri •mlip to addition"to set Ling the form to
Icn f` known): the address(es) oboire. also submit one' • of this fotmi ilTltbiil'A0 days of
comptetian"of wv ll abandonment to the county heAlth dcparuncid of the county
61%toner casin+gkohing fimoth(d known): _ (ft.)
11-h=atbandotl4
6g.Stiven length(if known):
i
Fatm GAI-10 NonhCam im Deparinru4 afEmitoonvm mad Naiwal Resmriees-Disisiaraaf Water"oinces Revised Ai"sa 2013