Guilford_Well Abandonment_ (14)

I
WELL ABANDONMENT RECORD For Inlerrutl use ONLY:
This form'canbe used for single or mltltipte mails
1.Well Contractor Information: WELL ABANDONMENT DiRTA1L5
Brian Ewing 7s.)Number of we4lt being,abandoned:1__
WdUtotmett Nome •a %iitoweerpusaniny,omndoning,kwtbewileerprupertyl For midapk tiiktlr�t w• noFj-Mciter $I**- volts ONLY will) tt�e 'Voit
t cova rrncter�v 4vl raNchuivuw)t,tom coot svlvaut ova furor,
4240-B
7h.Appr oximotc volume of water rJeteaining in well(s}. (�L►
NC Well CoulmdorCtMi6catiatiNmnber I "
SAEDACCO Inc FOR WATER:5U?PLY IVFLL$ONLY:
E
CanVarot'Name 7c.Type of disinfectant used:
2.Well Construction Pcrniit ld:
L.w dfl40kriill4 well at r)rrlPk"(% ra airh',StAlt;t'I)rJturcti,I airt;r)tr,ek-)ttMnA'n ld.Amount of list afmant used:
3.Well na (check.well use):
Water Supply'Fhrell: 7c.Scaling materials used(ghoctt ail that apply').
❑A ailttual olv unidipa*lbb 0 Neat Ccmcn(,Grmtt tll l3crrtonite Chips.os PcIlcit
❑C=ihcmutt(Acnting CooliingP Snppty) McMdential%Vatcr Supply'(sineic) ❑SAM Ctmcnt Grmit ❑Dry Clav
❑ledusirialrCornmcRiai DResiticetiat%Pater Supply(shwW) ❑CotiercteGrutit ❑ Drill Cttitings
l7lrri tiou ❑ Specjahy Grout 0 Gravel
Nttn-Water suppty Well: 0 Bentonite Slurry d 0ther(exTlain under'7g)
�)Nariltatirq� ❑ltecove T
Inj pu Well: X For easli material selected above,proside amount of tntiterialsp-sed:
❑Agtiifef Rcchat� ®Griiurod4rrittr Rin"Ation
i7Atinifer Stota a and Rccmlety psa ituty®airier
❑AquifttTed ❑Stiiniiit9tltDra€ttilgC Bentonite. :150lb ,Wtr:gal.
pExperi:nteniai Teclru®lv tt OSiybsi fiee Colitt[rl 7� Prirsitic 5t iirti:f�iii riptioa ttf the alran@trirmeat rtyrt-alure:
Meotltennal(0osed loop) ClTracer
Removed DPT Tooling and abandoned boring with hydrated
DGeothenual(HeatiiogCooli2a Return) 00ther(ea lain under 7 )
bentonite chips. :„!i�''
4.Datt:sietl(4),abanrlonerl: 06/25/2022
Sa.Well location: J
Former Cotton Mill Square Site Inir"xf' "�� x'l '^ 3 ng
Faciliil,omrxrMUM FacilitytDotirappti=blc) R•Certification: Jv'r�llu�
801 Merritt Drive Greensboro, NC 27407 Brian Ewi n 8/10/2022
Physical Addres.City,and Zip sc vVetl Corim lor:�r w 411 01VMr Date
Guilford fh) signing this 1 lrernhy cer•ly that the wellfsj yeas(were)abandoned hr
Coe my hredldcntttic t"tlio.(PIN) roavn-16hew vith 1 M XC4C 02C.0100 op-2r—.0200►bell _4jjStntc(frrn Strmck'irds
mild that a cap offiris record has bee•)r prodded to lire mwfi owner.
Sh.I atittrSlc:and lnngitp'de in degrccslnitnutcsEscrrinrl5 or d4Cttn it d't grrcc;
(ifisttl AW,otte 9.Site diograua or additlonal nil lelalis:
You may use die back of this page'to provide additional veil site details or r»tl
A �Y abandoraneot details. You tuap also attach additions pages if necessary-
CtlNS'TRUC"1'IUN DET'An S OF 1'V€WS)HJUNG ARANOONI"_D SUTIATITfAL INSTRUCT'IO�TS
Aaw*vtjell cr5arrruettrirt rvmk l(a)l(ovWfre9le_ For trrukipk 1)tfedk)rt(su wn ww4 r--Wpph,
Ntia(Lrs flNLY;t irlo r1m na✓Jrc ncarr+amRhrft lute;rnn. 10a. For All WdDsc .Suborn) IhLs!form nitltin 30 days of completion of wcll
6a.Well @a:CAT-16
abanilonmcia to"thc following,
Division of Water Il ft urm,information Proceming Unit,
i4i7 Abii Sei-Ace Center,Ruleigti,NC 276"-161.7
6b.Total well depth: 57 4)
10b.far tn_icctl(en Wt ls: In add'l.'ttoo to sending iv form,to the address in iN
6c.Borchole diameter:6 above. py
.also submit one s 'of this fora►ntiiltin 10 days of completion of v%*Il
(iu.) ahandonutctd to the following- 1
DiAlsion cr Reno c CUnderground Injection Control Pmgrant,
6d.Water lct'4 belly' nnd surface'. (ft) I636 A otter,ftalc%h,NC 27MM4 636
6a Outer ca ling Icnt{fh(if known): ( � for.1 or Mtm SrrmAy -blmthrn'Wells:. err addition to sending the form to
the address(es) above. also submit one"Copy of this foren AAlthirt 10 days of
completion,of well abandonment try the county health deparueenj of the courtly
6f.Inner cagin�tmlring length(if knovrn): fft.)
i aWndoncti.
6g,Screen ienob(if knomu):
Font,G111-10 NorthCarotim iJepsnincct ofEnOronment and Natural Resources-Di%,Won of Wztcr Resoun:es Revised Augrsl 1v?i3