Guilford_Well Abandonment_20220818 (11)

NVELL ABANDONMENT_RECORD For Imc mil UW W Y.
i
77tis form caa be used for single or multiple wells
I.Well t ontradInr Information: RIML ARANDCONMENT DET&M
Brian Ewing la.Number of wells being abandoned: 1
wdreounaclorNmme("weiltownerpesorall)aMridanin;utilonhLgflrtptapcny) Far widtrrfe fe{ fmi ar notmi4iter sirplrty OF4011S ONLY Wall MT CMIC
enrt:rrnctk�,r:Saha�rr�a�rent iwn cmr,mhrS�it eve Tama.
4240-B
we wol Conic termattiun Nmn6tr
71►.Appnrt:innitevolutriL of water"kre Aiding in
SAEDACCO inc FOR WATER SUPPLY"HELLS(?XLY:
Cdv,VUMr•Name 7p-Type of disinfectant u3ell:
2.Well Construction Permit#:
IL•t tr/f ry ,lkx�h welller rPia n':r Cyr+q.Sr�r .try rrrmti.T,y�ci r t:.et-..)IrkimWn 7d.AmottnCof disinfectant used:
3.Well uar(chcd:Well age):
Water Supply'Weil: 7c Scaling mataerlals usW(e 60;till that apPIO:
❑ferry lama! ❑mtmtcipavptlblie• Q Nc at Cement.6mut tR 13cr4oriitc Chips or 1'ellt is
l7t1catlaerttutt(Ile rtingiC ootina Supply) ❑ltcsidertrial Water Supply'(tingle) ❑Sand Ctntenl Grout ❑Dry C�itit
[ Industrial/C nmicrci ra Dltssidential Water Sultpply,(sltrtmd) ❑.Concrete Grou/ ❑ Drill Cuitibgs
t3firigation 11 Specialty Grout ❑ Gm%*]
Nup-Water sopptp!Nell; 0 13entonite Slurry ©Other( 'pla€n urlder 7g)
❑NINtildting Olecowly
injection Well: X For cacti utaterial;:elected above,proside arnotint of tnitetials Wed:
❑Aalttifet Recharge MGnitmiltvrlter Rtutetiaticm
❑Muiler StOme and Ricek et'y ❑Srrlinity Barnet
Bentonite.:150lb ,Wtr:gal.
❑Aq)tifer Ted tlStattrttiy stet T1fu tYt�e
❑ExVe imentalTechaolop ❑Subsideme Cbi tall Ir Pitnide r Nw. description of the abAndannimt-procedure:
DGeoitremtal(Closed Loop) Mracer
Removed DPT Tooling and abandoned boring with hydrated
DGeothemtal(li ad Cook Return) 0Odicr(explain under? 1 7 q f
bentonite chips. - ;r r
4.Dat0wcJl(s).abandoncd. 06/25/2022 ,
—P.iSrTy-C��
52.♦ell hteation:
15'71-Gt7 Iwu.
Former Cotton Mill Square Site I DINQr�OG
FaciliiSKlcrrtiorNnyatc racM),ITO( agplieiblc) S.Certification:
801 Merritt Drive Greensboro, NC 27407 Brian E1N1 n 8/10/2022
Physical Address.City.and Zip $etit#Irtc7e oP Dme
Guilford By soling this foray, I hemby serf ahat the weli tt rafts prere)ahturdaned try
Conti}• Parcel Identifki"timiNo.(PIN' tt;Ysdancvwi#rlVA'CAC62C.61 ,0.ur2C.0200fFdll;Ct�atstrtlrtitin.Romkrds
) u
and dwt a copy vf'this record lun beew prmided to tire v rll awner.
5b.latitude and Inng,de in degrccstmirtutcil nd ryr docIfim,cl+ recs:
(if-kn rield,tyre t:au'Wtgrs aeii) 9.Site diagram or additional,%al;decals:
You.may use the back-of this page to p"rdnide additional stell site details or null
A' W abandonment details. You may also attach additional pages if necessaq.'
CONS
CRIXTION I)MAILS OF WEL US)BEING ABANDONED MINIMAL INSTRUCT ANS
rl(M rirdl cw4y"awirt rrrxirft)jrovhflaM. 'Fit-m,rlfu,te i*t*e)ri:6)•- swA�
IwAs'oAf u-IM firm�ium-c�,:nsGrreeikoar'ahnirckunr�crot�1om r-on A C Mil(ute)b"ir_ 10a,For All W&o: :Submit this hum Within 30 days of completion of well
6a.Well ED CAT-14 obttitdrinmcni to the following:
Division of Ulater Re"urces,=Iullormatir n P,rocessntg,Unit,
6b.Tofial ivell depth: 57 (ft.) 1G17 bull Service Gtater,Ralcil#i,1NC 276"-1617
191A For Inle tlon t reps: In additi a to sending die form to the address in Ilia
tie Borehole diameter.6 above,also subiltit one =of th s form ittitlkhi 30 days of completion of trell
fin') abandonment to the Mowing-
rd Water level helms rtrrtnrl surface: Division;of Water Resources�Updergruund Injection Control Program.
1636 Stall Sake 4rrtcr,Ralcigb,NC 276"4636
10Ct
tie burnt a:asing Icn (if known): (ft l he. ForeW;aft above. i
also
M tinn"'1�'c111. in addition to sending i.lye form to
t one copy of this form mr tbid Aft dns of
completion of well ahandoament to the county health depamnent of the county
6E lnnercasingftnlrittg length(dtyronn): (ft.) vvInre strandoncd.
6F Sit length(if!corm): 00 1
Fomr GW-:tb Non hCamilm Departnrcgl of Emiromnent and Natural Re mas es-Dltlston of Water Resoarces ReAsed Agasi 20t3

i
WELL ABANDONMENT RECORD Far tnienail lase ONLY:
Tbis foim can be used far silt k ormultiple nmells
1.Well Contractor Information: 3&ELL ABANDONMENT AEfiA1LS
l
Brian Ewing 7'.Number of wells being;abandoned: 1
%VNI' 'owneforNamc(ar wmllownm pcisarutly..iliardoning well on hLatlkrpr"y). Fcu• w1rh ote Nve0rair or mml-ilWer sigph, wells' ONLY wilts .11m x0it
scH,*rrncnrn,,4�!�rnrrh�rr!tnru,�rinr�rs<vlx!Flr+xiefrrrnr,
4240-B 1
NG
7b.Apparxinomte%volume of watir:remitining to
Wctl t'onir<7aor Canifi�iiair Nmrfra I
SAEDACCO Inc )Olt WATER SUPPLY NVELLS"ONI1:Y:
Cdnq+mriyNamc le.T-*Vr of disinfectant used: E
2.Wdt Construction:permit 4:
LG.q 01 milhAtte wei1p raml6(� 1 Cu n tv,StmM;Pei riam1e,1)rf ioP,eft--'trkltowM 7il Amount of disinfectant u :
3.Well uk(rhetl-Wdl u:xc):
WaterSupphyWell: 7c.Scaling materials used(eh Pill that apply):
OA irkijkumI ptvtnnieipxl/Pnblie Nrtot Cement ut IR I)crttonilc Chips or Pcllpts
170mothctmnl(llcating Cooling Supply) ❑j7csidential Watc,Supp4,(single) ❑Said Ctnteni Grout ❑firy Clay
❑Indusitisil/Commctsial ❑RcOdcndal Water Supply(sliv1) ❑ Canetete Gtoul 0 l7rill Gittdtigs
olrri tiort ❑ Specialty Giotto ❑Gratrel
Nion-,water Sn�Well: 0 13erttotute Slurry 0 Other(ex;plain under 7g)
❑Monitorirle . ❑Reco�
111joction Well: 7f.For each.n_iaterial selected above,proside amount of ntatcriais'psed;
❑Atluifer itecharge OGroundwaler Retuddiatimi
t7Aquifet Stoup and Reeovetir ❑WinitV Barrier
0Ayuifet Tt-st I7ratnage
Bentonite.:150lb ,Wtr:gal.
❑Experinteotel Teeltnotoirt ❑Subs3det5ce i''ti►Mtt51 7g.Novi&r.Irritf 6cription of the abandonment prpmdum.
OGeolherinal(Closed Loop) ❑Tracer
Removed DPT Tooling and abandoned boring with hydrated
CGeothenwl(HeatitkgCooling Return) ❑0tkTtea lainnrrder7 )
bentonite chips. _
#.Date arelt(s)ah,7ndr�ncds 06/25/2022r -
Sa Well location: p,jr_, 2022
Former Fm:,1ftyA)"-r0rNton> Mill Square Site Fasilih,ITO(Vappli:61cl Itlr�f�' `� r'f C , s? Un!
tl.Certification, c
•
801 Merritt Drive Greensboro, NC 27407 B_ri a f' E r1 8/10/2022
PWsicml Address.City,srrd.2ip r Ltd ec tirr iivied vL:tl Cnuer rnr; r'.11 OhvMt 11,44
Guilford fat .ai'VZtrrg this fa7j,.I hemby certify that dw trellfs)urax(irevr)a'h andoned in
Gourtiy' J)Wod ld€ntlfiti"Wo.(AINr ratc�t lchW►vfth PV X 4C 62 ?010l or-2r .(t1.00 Pc11Cons ruetiov Awkirds
cmd thai a cgpy of iris record lrrar beevr ptrnvded fo dre m-ell awner.
h.11&ttQrcicartd longitude in dcgr+ealrninutca/secondsordecimal dcgre .
(tfwell Earci,ove 1:urkgtg is S10151 cup 9.Site diagram or additional well desalts:
You may use the bade of this page to pfoAde additknial%ell site details or i%Vll
abandomuent de'wits. You may also attach additional pages d iiecessaty.`
CONSTRUCTION bfi't AILS OF WLLUSl BRING ADANDONIr D SUBh117TAL INSTRUCTIONS
,fliLth,nrll er,rzrA7rcfttt rrr.vi,d(t)I(Ovajwk- :Proiturltip/e byerrtr!r ,r,a�n.>rueer it alti
UW&ONLV u-Ith the aranm-rotryr!wrriolc>'anrtirekervr!rnu.;inn ea�r,sar6mli wte kmrc 10a. For All Well t Submit this form ti•itl in 30 d; s of eompletimn of well
62.Well 16l7"CAT-15 aban4onmcnt to'the,follotving;
Division of WaterRespurrrs,Information Processing Unit,
6b.Total aeIl depth:
47 1617 Mail Seiyitx Center,Raleigh,NC 276'19=1617
(ft.)
itlb.For Inicstt n.31r Ils: Li adttltion to sending the tome to the address its IN
6c Borehole diameter,6 above,also sabiitit one topaz of this form tAthln 30 days of completion of av:11
(lu') abandonment to the follinving:
Diaislan) c 163E t1�l R Iinderfiraatad IttJclon Corttrol'Program.,
fd Rater dad hclrnr grna<nd surface:. ( C trter,Raleigh,NC 276"4636
e address(es)M5ilaelaalso sub' n MIA: In addition to sending the form to
6e 0utcrcasing length(if laton nj: (ft) 5t done copy- of this fomt afrithin No days of
completion of aireil abando,nncnt io'the couidy heuith dcpanmcnr of the county
,whcrc abandoncd.
61%Inner casin hnbing kmgth(if lmown): (ft.)
I
6g.Sawn lettgdt(if Itnuwt): (ft.)
Famt G1V-10 North Camlim Deparlmctb of Emd o0ownt and N:uuml Resounes DIs isboa of WaL-r Rchom ms RcAsed Amiss-V l3