Guilford_Well Abandonment_ (15)

NVELL ABANDONMENT RECORD For Irdcrasiltlsc'ONLY:
This fbrtn cantle usedfat single ormtdiiptemdls
E
11.Welt Contractor Information: SWELL ARANDONMENT DETAI
Brian Ewing 7'L Number of uAls being abando ell: 1
�'d[Cantmetor Name(or Knit owner ocavn511y a1��nlm-wci!on tii�lk&pT ay) For widUple 0yWHot ew mrj-v.'id sirpmN, Wells ONLY Wtth ►AT nTme
rrvk,Rttcttr�v�rlrnaxhni'rruenA,�riry cwr rnfvnl"r,�rrfrirnr,
4240-B
AIC W�1t 4bnlnc�AarGeiliftallicin Nmnbcr 7b.Anlldrxirnste�"vllntrlc i�f vrnt[v'i rttiainin�in vt�ell(x}; �gL)
SAEDACCO Inc FOR WATTR SUPPLYA%t"41 S ONLY:
con ati+Name 7e.Type of disinfectant used:
2.We11 Construction Permit#t,
I�sr all iliaxihh a"lf as rmlty f.at rrlr,,SM4 ;IjdHilm r,/Iffe iftnft„err t 7/k nr ra 7d.Amotm I of disinf ct int used:
3.Well use tcheck well pto)
Witter Supph•Well: 7e.Seining inaterlalc used(chock All that apply),
17Agrpctiltttr et ❑3,Ittniripal/Ptibiuc, ❑ Neat Ccmcnt,GMrt N Bentonite Chips or Nllcts
t7Cictathcmrl►t(Heating;Cooling Supply) -okesidentiol%Vatcr Siippty'(sitte)q) ❑ Sand Ceuteni Grout 17 Dry CLAN,
❑lnduStridilCommcrci:tl ❑ltcsidcntiat 1VaierSupply(shared) ❑ Ctrnctte Groinl ❑Olin Cuttings
❑Irri lion ❑ Specialty GtoLd ❑ Geavel
Non-Water Supply Well, ❑Bentottite Slorly E3 Other(�°plain under 7g)
❑mmitto&e ❑Ftteo '
In jectilon Wen: 7f.For each',material selected above,pros ide.amoutr1 of,rmi teriais used:
❑Agrrifei'Recharge ®Grbandtiraler Rentediation
IjAilidet StcuAgeand Recovery ❑saliidty,Badet
❑AiluiferTest 13Sf6rMvitterl?titnage g 1'
Bentonite.:1501b Wtr: a
oEraneriietental TetJnnalogg OSubsidente CotNrol 7n,Prmidc s liri�'i. ription of thc.andndodment p"mNure.
tGeothennal(Closed Loop) ❑Ttacer
Removed DPT Tooling and abandoned boring with hydrated
®Geotbet'rttitl(tieati ACoo[i Return) ❑Otherlea lainunder 7 )
bentonite chips. - F"�
a.t)atctscll(s)abandoned. 06/25/2022
wE =5 iV k�
5a.Wen location: AUG ! 8 Q -
Former Cotton Mill Square Site ( n'.'
Futil6y?t,rtrNuw r-xility tD;U(aQuppl cible) S.Certification: C5° ��li.r`C
801 Merritt Drive Greensboro, NC 27407 Brian Ewi n 8/10/2022
Pli)sicyl'Address.City,grid Zip Sr gliiAeafC ditiad Well Cnri9 lat .rr li Ortiitiee bloc
Guilford !3y cegrrAr{r this form, 1 hereby crrirfj+that the r'sllf,)Hens poem)uhevrdoned irr
t amriy Pamd I_demtltteationNo.(PIN) e'rttvrdaijee +f1h f�tf XCAC 02C,010-0.r r 2�;.62%tf lf"vil Gaaslr 1E-f40ri SYrrttiJaW6
ar d ffrM a coptrr+./rllris rzmr•cl bun-bErn prmiderdido 11re well awner.
5b.140tudeand lnngitutle in dvgteC tmintitcsslseprn4s or dccit"l dcgrces:
(if isrllra0d,aeE bivUl tg is sidricicitt) 9.Site diagram or additional well lela�:
You:n q use the bacK of iltis page'to'pm'ide additional%ell site details or tvV11
h' W abandonmeru details.'You roa►'also attach adtiitionaaC pages it taecessary.
C'0NSTRt1("TI6N DICTAI1.S OF WELL(5)1iMNC ABANDONED SURAtTTTAL INSTRUCTIONS
.�tr6atir si�e11 c»nvinixrf.�re rr!tt.,reAdx,7 f{aa61Fte9k_ l"rar tiruhif�tr iujYefirltr tar i�rnyn•ctdis,'su{tfah!
"VI&ONL'Y with&&?MM , Vn caroaadhmh fore fi_ ' 10a: For All Wells. Subucit 11rts'-form tit7tliin 30 days of completion of cell
6>i.Wen I1D#.CAT-21
8bandonitcat to the following:
Division of Water tCtsYrurets,.Intforrnation Protemin4 Unit,
I6I7 Mail Scr3ice Center,Raleio,NC 27tieM-4617
6b.Totil Fell depth: 67 (fI.)
10b.Far Inleatlon Wells: In addiaion to sending the form to the address in IN
6c Borehole diameter.6 (in.) above,also snlrntil one `of this Porn►uithin 30 d*,s of completion of n-ell
abindonrneut to the Ulowhq,
tG
Pir islott t11ai1$ fTridergm.ud Injection Control Program.
fid.4lratef l�'et bclrm*0,ound su (ft) csti
rface: enter,Raletgle,J\C 276"-I636
k
0utcreasin length of tmmtrnp (ft,) 10c,For WaMx Sriggl•A Infection'WYells: In addict'ott.to sending The form to
Gc
fi �'(` the address(es) abo�'e. also submit one copy of this foini within 0 days of
completion of well abandomnent tie the ooun1y Itcialth depattmem of the counts=
61%Inner emini puling length(if lemon): (ft.)
uiactc ttl�ntloncd,
bp,Si rent lengtlt(if known): (ft)
FamiGV.'A0 Nontitamtien Depanruaoi afEmvlrorumeal and Natural Rewomes--Diiisian of water Rr`somees Revised Aimed-Vil