Guilford_Well Abandonment_20220818 (5)

WELL_ABANDONMENT RECORD Far laricmilU4eONLY;
nds form can be used for single or multiple wdis
1,Well Contradorinfnhanationt RILL ABANDONMENT DETAILS
Brian Ewing 7a.Number of fA,rlls being;abandoned: 1
\vc3tl"raaal>3clorrra r,�r� ttav� �m u�a g Hctl on liEliirrprmpcny) FCkr withipk r qkWtar w• mara tt r suPPA, mra115- ONLY will) Ae rwle
cwi*eerie/lcay.4 arrk aerie,�rrrr cwr,mbiiir tau fame
4240-B
7b.Appnht:imate volatirne of watcr�r inaining in Avll(x
NC WO Cbrilricfort dn1r 66fl mrkber
SAEDACCO Inc FOR WATER SUPPLY ANFLLS 0XV11:
CarrVatii+'Namc 7e.Type of disiufectunt u3ed:
2.Well Construction Permit 4N:.
Lae dll 41itkvitle wellA rmi a n.r•C u rav,Swka,Jildriamie,lrry*wiiom rte-)#,k2rr*ri 7d.Amount of disinfectant used:
3.Well test(che&well,me);
Water"Supply Welk, 7&Scaling liaat a9 r fiscd(OocR aill that aliply).
❑Aerrct_dtu ml b ltuticipsUPtrb4 • �1,Tir t Ucmchtt-frt[Kn. dd cmonite Chips yr Pellets
❑Gcothcr hat(14catinglCno in Supply) OTtcmd ntial%Vater S0PP4(sing!,) ❑Sand Cement Grout ❑Diry`Clint
❑IndutttiallCommcrcial ❑ltcsi&nflul Wolff Supply(shared) ❑ tonerefe'Giotil ❑Drill C►tii3tigs
alert elan t7 SpecialtyGboid ❑ Gravel
Non=Beater Supply Well, 0 Bentoftite Slurry ❑ Otkr( lain tinder 79)
❑Mc ad-tinje" ❑Reed-to,
injection}Veil• 7f:For eacb tttate_rial selected abore,.proaiide atuotthnt of rr_tateriaisttsed:
❑Agtufeai"Itrcharb�e, ®Grgaiidttbler Ittrnedi'Hrrth
❑Aq uifcr$tt"gle and Witty p$alfirity Border
❑Acjilifei Test oSfotnn3t�tcrlXnlnage
Bentonite.:150lb ,Wtr:gal.
IlExpefintenial TeOutolotsy ❑Sutas3tlelfce CtirN# l 7g,Pkmidc a heidd6cription of fiic"uhAndourn nt pirrc(dure:
DGeotheaml(Ck+sed Loop) 07tacer
Removed DPT Tooling and abandoned boring with hydrated
❑Geotltetemxrl(leoti of Return) CStJtherflairs under 7 k
bentonite chips. Tom ,,
d.Datvwutl(s)ah:hndnncd; 06/25/2022 .yto V
5a.Wefi hteatinn: AIJ(; 1 S 2022
Former Cotton Mill Square Site r� .rx.};�
FaCilin'?t*keraCrTittmc Fastit;•IJ.Ntti6vpptic;rblc) $.Gcr9tllc�rflonc " 'l Uric
801 Merritt Drive Greensboro, NC 27407 B_ri a n E of 8/10/2022
Pli}steal Addms:Gill:and Zip 5t hrreof�kiiif d 4ircil tfim M.0rrr,.Y,[i Q,r r Dille
Guilford ,,ci rin thistheta, Y herehy Certify that the vvilf(s)way(ivere)aheutdoned ire
crrorriy PaW1_deatittaiironlio.(Pled) e'tctvrdatice frith lf.f XC4C Die.01#0.or 2C.#200 5Ymckrrds
and drat a copy of this r'eard bin beoi r prvavded to"tire t,-ed awne•r•
Sk l atlt+trde and!ring-0 do ire degmalluinuteilkwnds or tl+ iRud degrees.
(if"411 fz Wr1,(rile:btioas 3Ssaflricecr!4) 9.Site diagraur or add9ttroslal well details;
Y6U,nlay use die hack:of This page to pnivide additional urll site details or nmll
)\ �V abandonment details. You tvw also attach additionat pa&s if rlecemry
t'ONSTRUC ION D1 TAIt.S OF WPL1111 IWING Al3.ANot:NM &URAiIT)fALJNSTRUCITONS
Attrsttr iWe wart wefian ia1[YYtrrtl8)tt r�rTretlrahlrt ,1"ria ahttltipke infeddrrrr.pjr"hA3ra-M Naff fapfy
1411a NLY+r•it•+a ilaa ti rntccranerioar'exDoiratrammewtr.�etn raro arNa(i ure kern_ ' 10a:For All Submit this then iiithin 30 da5 of completion of nrll
62.Well U3iI°CAT-32 abandonrncnt t9 the fat�at'ing:
Division of NkIl ner>tes>urcts,7nfanhation-Processing Unit,
6b.Total%vil depth. 90 [ft;) 1617 Mail Schice Center,Italeit� NC 276994617
fob.For Inlection Wdlls: hr addition 16 sending the forut,to the address in 10a
6c 8onebole diameter 6 eve;Sim subriduoue bM of this'loran midliu 30 days 4 completion of AA1
a".) aba hdomneot to tire folluning_
DiAlstort of Water Risoukes,iiu lergrou'ad Injection Control:Program,
6t1,Water`del helnw•grnund surface: (ft.) 1636 Stall Since Ceirter,Raleigh.N MT)i636
6c.l9utercayng icn flh(if Immvo): (£w) l©c.Far Hate,,&I Min•AInfection Wclia: in addition to serhding the forth to
conipkitressof ii abardonn ent tot rionhrt hcave. also subniit'One cM, of irih fo n r�diof tb days of
p } deep he coahnh=
6L Innercasingltubinl;length d£I,yhona): - (ft.)
tthrrc Amildoncd,
i
6F,Screen length(if known):
Form Ca1V-:O 'North Camlhn Depurinx.at ofEAdromneni and N:uumi Rcsauzecs-Division of W'.iterRocurecs Rcviscd AWsi 0B

i
WELL ABANDONMENT RECORD FortrAedwlUscONLY:
7tris fordo can be used for single or mtd!iple w0s
I.Well Contracfo'rlurannation: )YELL ABANDONMENT DF'Ti►1t.
Brian Ewing 7a..Nutnher of delis being ahand�ned: 1
1,1rdl towncIWName(of nla rAonlni,oA on hRtlterpropFiky) Far wirtttpfe byedto.;i rr sit p#1 `rolls. t7NILY with .ffir avit,
ear:.trncrk�+a,4rfanurhn�i�uaer:f tr:ro ciur.nu�rlf'rui�+fnrnt.
4240-B
€
1JC Wn11 C'tonlriciaiCcrlif�lar�itNrlmSer 7b.Apjtitizi»tate vytinutti.oitt-:1t f t'�mariitnu in (gat)
SAEDACCO Inc FOR WAITRSUI'P.l.,t�tIHT.LS ONLY:
Cant)any'Namc %Type of disinfectant used:
2.Well ConstrMion Permit#:
List hit oppitrrrhk tvrflnrrttr(i.t Corrrrtt, tcv,7 cirtruK4,fiilrtiarr,rr,l Pfkerc� ra lQ Atnatlnf of d3sS.nfeetstft used:i
I Well par kheck-well u );
Water Supphr Well: 7e Scaling materials used'(ehocic A That appl},):
bAeaicaltum.1 t71r1tori ilipitPttblec NcatCsmettt.Crtt>trt $ciftalnatcGhipsorPellets
❑Gcothennnl(iileatingCpoling,.Supply) ❑ltasidential%Vatcr Sitplily'(sinele) ❑ Sand Cenierrl Gi ut ❑Dry C ky
❑lndnstrialJCammcrcial" ❑llesiclentialWatoSutipl}•(st=Tcd) ❑ConefeteGmut ❑DrillChiling,
01frigation 0 Speeinitf'Gtow ❑Gravel
Non:id-u$uppty Wclh, 0 13elftnite Slurry 17 Othef(explain under 7j)
❑monitorLke ❑£teco'+er_R'
Tnjection Wen: X For each material selected above,provide ainnt(ot of materialsnsed:
❑Ayuifef RtchaF0, Reuletlituic)n
t7AguiferStaruge and Retiwery CiSalifdtt Mtrier
❑Agnifot Test 13Stortintvater Dniiaage
Bentonite. :150lb ,Wtr:gal.
❑Eapetfntenlal Teehootoj pSubsideltce Control 7r,Piihidea NW—description of the aUundonment pr*wedun::
Wcothenwt(Closed IA+op) 137racer
Removed DPT Tooling and abandoned boring with hydrated
Meothenn2l(HeatineCoolipa Return) 0 Oft r( lainunder7 ) a ,"
bentonite chips.
4,Dats,wa(b).ahtndnned; 06/25/2022 Ails i S 2022
5%Well locatio :n r-.L�;1 �ni3
Former Cotton Mill Square Site
Fn01i't1,0wr rMime Rxrlity.TDO(Vlippl=btc) >l•Ccrfificatiotls
801 Merritt Drive Greensboro NC 27407 Brian Ewing ng 8/10/2022
P'li}sicat ►dkcm.C-tV,sod by 6cc la�M nl Georg Well cojor err,.r.qtf p�ri�r Dole
Guilford 13y signing thps�form, 1 Hereby certr thud Me wffifv)was 6-0 aheuidonerd nr
Cnutily Pmed ldcrtdfk�d6iiWo,(PING amij-Mite ah 1,V XC C 62C,0100vr 2C.0.200 Smmkmds
emd Nud a copy afil ds rzwrd has bMe pronidedla dire well airiwr,
510.Latitude and lnngftude in degreeshninuteitsmndsor fteim,il degreeF.
(if*cll ned, g.Site diagram or additional well iletttitc:
You ma} use ilk bawl:of this page ioprovide additional well site details or nvell
Its W a6aildonotent details. You may also�attaclt additional pdges iP necessary.
Ct)N913HICT16N b)`t AILS OF WEL145)HEING AB kNDONE:D SUIRMTTAT.INSTRUC.TiONS
Alai tr d l'J rrixstiAw1ktrr ry tlid(p le owitrs9te_ Pit,mithipf injedlrm(r roinorid&,tieppM
n ester la1tL1 uttA the anon ewisrnvrilnrr'id+altclrunr� rlr,i in rnn a�hnett rum i►in_ lta�Fait All WdN Submii this form nidh n 30 da}s of complction of well
69.Well[D CAT-33 abandonincM td the follpiving:
Dii'iiian of Water Re%)6rces,Infurmati►a Proee ssinl;Unit,
1617 Mail Service Canter,ittile,0,NC 2709.)-1617
6U.Total vicll deptU: 100 (ft.) _
10b,For In.lc Rm.tiYC ls: fro additioft to setidittg;tUe fatni,to"tl>c'addlnss in Ka6r-Borehole diameter.6 a') abo've;also subtidt one , of tbi i lbim ui lion 30 days of counpiletibu of 0*11
(l abandonmCid to thefollal itig'
i
tK Waterlev(d hcicrn groun(1 Sltrface� (ff,) Imstort of Water Resources;Undergrouad Injection Coatrbl Program.
163b Ilfail Service f,"c6 ter,Rafe=`-h,NC 276'04-1635
loc.For Water Sarnnly& Inicctinn 3U.118: In addition(d sending the form to
6e Outere>tan�Icni ih(if known). 010 the addfess(es) above, also submitlohe Copt of this forrn iAtbin -10 days of
ki co" iam,of well Aandonni<nt toltt a cmtm -heafth delitirtment of the cm1w,
6f.inner eitsine;/tubint k�trxKh(if latown): (f't.) where o i
I
6pr Scree ten (if luau"n): (ft)
Fomi MI-10 Noah"Caroli>m Depanitxim of Environment mid Nirtiral Resoumes-Division of Water Revised Aitpa 2011

i
WELL ABANDONMENT RECORD Fotinic id!Us:ONLY;
This forrm can be used for single or malliple wells
1.Wen Contractiar Infonnntim )YELL ADAND01011ENT DETA1ti,5
Brian Ewing la.Nuntber of wells being;alrandL.'l: 1
WelCCar�actorNaet�{orvbstl.o ncrp_rsnnally:absnitunlncacilonh�ti rpTapcflyl �' earctttpfr trje�t n aP ri Iatrr sa�nph twos ONLY will; Me roir
G-0vasrt•ttchrev°irJrurrlrinxuerat,�r,n rar mlvittr avlcf�rnt.
4290-B
NC Well Corm. for C.eriif=tiotiNumber 7h.Apt►nrzirrrnte>,Ytiutttc of Brat r>rrtiaining in wi ell(x) ( aiL)
SAEDACCO Inc FOR WATER SUPPLY WELLS PLY:
Cazr >Ln+Name le.Type of disi afrcKant used:
I
2.Nell Construction Perra t 4:
LW 01 41sh wbk well permits 0 t!Ccvmh,Aik VdHamw.litkefion,e0 fjknowo 7d.Auiottg t of d7sStt#Ytal]t Used.
3.Welt flat(c6cad:nc�1 uttrri) �
Water Supply Wrell: 7t=.Scaling rnateriafc usm(chcck AIl'that apply-):
17A r rtltrt l Gilvl4yricipat(Pttblic. 13 New Ccrncot.rout 5d Bcrytonitc Chips or relicts.
�(a`CAEhertnttl(1-1rratingr Coolina SiWly) 13Y2esidential%4`atcr SOppb,Csin tej ❑Sant)Ctllfit ti Ceottt ❑Dry iClut'
❑industrial/Commercial ❑lw0clerdialWatoSralip4,(shared) ❑C015GreECGrew ❑D611Cftllings
❑lrri flirt o Specealty Grow ❑ Gravel
Nian-woff Supply lYctt; 0 Bentonite Slurry 0 Wier(eN IaiautEdez 7$y
�Marittadrre p4ecowly
lnjocti4n Well. 7f,For each toatcrIial selected aboie,'proside antoutrft of nvAterialswked.,
❑A£lnifer ((change MOrnurniv iller.Ren lion
DAl dfer Slots*nd R2'Oveq, pSatinity Border
❑Aguifei Test OSltrrrSivtilter Dasiialgo
Bentonite.:150lb ,Wtr:gal.
pErp airneatal Tedinolokv pSubsldetace Control 7t,;,Pto idc r Irrd docription of the abandinrunent pr wedum:
lnGaeothaeawtl(Good Loop) OTracer
❑Geothermal Oleatial2oii2E Return) ,Mile r 4,explainuodet 7 ) Removed DPT Tooling and abandoned boring with hydrated
bentonite chips. •;�� (�`'^y
4.Datcxcli(s):abandoned; 06/25/2022
52.Weil lerealtion: a -
Former Cotton Mill Square Site rt3�.• � �
Fai:jftAUwrterName FacWy iDo Ciru ipfic,wc) B.CcH11[ ttioil: v 'Jry �
801 Merritt Drive Greensboro, NC 27407 B ri a n win 8/10/2022
Pliysieal Address.Gity-;:w d Zip Siyzjl.tra of Cirttt*d Will Ceiar jot** 411 01yeer Dow
Guilford 13p si rrira this,jmwj,_1 hereby cerrsly that the ar•ellfs)was(irem)alirurrlaraed hi
Caow, Pare Ideettmaiti a No.(PIN) attYndatfee with 1 J CAC,b2C•01 JG or•?C'.0200 M41 Catislntedon Raw*irds
and dral a cope,ofthis rcmrd has becva prmi"to the well iiuuer.
Sh.1."tude and lringitutle in tl+~_Gr e�ImfntrteaJscmPAS or dbeoull dcgrem
(if-well£eaotd,one larttrypt8 iarlfi rrr) 9.Site diagram or additional lull derails:
You.nia) use we back of'this page to purvide additional well site details.ofinell
)~r W abandonment details. You may also attach additional p4ges if nece'mn,.'
CONSTRUCTION DFTAnS OF WEIA-0)$11NG ABAN lON1tD SUTiATMAL INSTRUCTIONS
Amach Neill rai,avrrinthre rccr3re/t'at if ov,5fka k. AF—muftipk•injetririm'r[a•kwritttXMI&*arlVha
e ellaONLY ri trA rfas a»nre rnirsvraedox'r onch�r tcrty, �,v rnm nrdurrlt are G»m 10a. For All W6s: Submit tlriiis faint Uithin 30 days of completion of sell
6>i.Well 16gigAT-34 abt ndonmcnt to`the following:
Division of Water Reso revs,Infiirritation Processing Quit
l617 Atlail SeriAce Center'.Rai '" NC 210hr)-1617
6b.Total well depllt: 100 ,fit.)
1'41a,For Inle>*tlon Wells: Hi additouto sending dt<ftrB►t to the address.itt:i0a
(� above_also subtitft one Copy of tb sl6mi umithlo 30 days of completion of'tkell
fie.Borehole diameter.6 u.) ubaindonorwid to ttte follawfi g:
i
Gel.Water lc�'e7 hcimt ground Marc (ft.) Division of Water Resouttres,Undergrotrad injection Control Program.
163E Mail Senicc C"dicer,Ratcigh,NC 296994636
6c.Outcrcadngicngtu(iflmoTim): (ft) 10c,FnrWater-:3 IMly L&Tuicctinn Wells: In addition to sending the form to
the address(es) above. also submit lone copy of this focni is;ithin:eft dws of
eomptetion,of well abandonment to the onuniy health depa nntent of the county
6L InnertwinttOnhing knOh(if tatonn): (ft.) whnc awrtdoncd.
I
6g.Scram lengtb(if Imomti): _ _ —A)
Form GW-30 NorthCarotlm Dep3rlm:a of P.ntlrournent and Natural ttesoomes-Division of y1 atcrRcsourcvs Revised Awgisi 2013

i
NVELL ABaA1 IDONl1'IENT RECORD FoitrderkitUseONLY; i
This form can be used for single or multiple wells
1.Well Contractor Infor9uation WELL ARANDONMENT DE'f'AiLS
Brian Ewing 1t.Number of yells hehig A indoLd: 1
1Vdl ContraciorNsfw iorwiou oh-ter rsPna11 al��hinln %,CU oil his/her Hein rttithiple -fftPolair a Mta�iwter SUPp , wvlls ONLY Willi .t w wale
1 S piny)
cm4trtrctkra4Tbnrrr1aurvarvu,Iran caur,cra�aidtzrkirfn�rt,
4240-B tl
NC Well Ctiih maor Ctilifttealiatr Nimber 711.Apprrrxitnate�vtluine of�attvk remaining in ruell(x} . (gat)
SAEDACCO Inc FOR WA'I'FR SUPPLY S ONLY.
Cattrpt 7l).Name 7e.Type of disi rfmantused:
2.Well Construction Permit#c,
l
14�r al ,frrui►t�uetiaerertr'.x 1;. C41"r►t,. r .peifTa e,l of ri r rr,ex.j tfkmawra 7d..Amorrnt of disinfectiat used
3.ti1'd�,uslt dchttd:n'til use};
Water Supply Well:: 7t*Scxltng mat6i4lc used(0604,01 Neat apply):
[]A�,ricarhnr(t Ql�tru►icipniFPtible , 0 New Ctmcnt Ormit 11 11cw6nitC Chips or Pcllcts
'13fi+rn9hcnnal(HeadikoCootin Supply) ❑ka,Wemml Water Stipply(single) ❑Sand C,entgd Grunt ❑Dry Clay
❑htdustriallC;ommcrcial ❑ititidenlial Water Shpp4,Cshwrrd) ❑C69mle Great ❑ Drill Cuttings
Olrti lion ❑ Specialty'Grow( ❑ Gravel
Nast- rater Supply Well; ®Bentonile Slurry d Other(plain under 7g)
❑monitoringe ❑R o�e1}'
inj Lion Wen: 7f.For each miater•lal el mi
elected Act%prde amount of matcl ials used:
❑Aquifer Reeha%w 09Gn0ufi&6ier RentediAion
OAt)rtifet SIM&ft114 P&%A M OSalildhi tiatriet
" Bentonite. :1501b ,Wtr:gal.
DAgrtifetTest �SlbrntStYrtetI)r stage
❑E:.prtinteutal Tecltnotov pSv6sirbetxt CittNrt51
w Pr,tliidc r lti-icf'description of the ah9nrinnmrent ph►cidure:
ifGeoihet l(Closed Loop} CITFacer ,
Removed DPT Tooling and abandoned boring with hydrated
Moothernial(Head i(;il U Return) ®Other(ea7ain under 7 )
bentonite chips.
il.aate�►'tett(5).abandonerl. 06/25/2022 .
51.Well k►cation: AUG ; b 2022
Former Cotton Mill Square Site ( �i�t t-mw—v,-inn Un.ij
Fame lowrrtrAttx rActlitylD4 fappiicabto? R.Gc"r1(ftcatictit:
yt�i�J�
801 Merritt Drive Greensboro NC 27407 Brian Ewi n 8/10/2022
Plkysicat Adilms.City,and Zito sisgnt1"t of Ce it 111*4 Wctl Cjit[rte1o#
Guilford P3 'Figning thisfarip"l hereby cerd#,thrrt the xellfv)way ry—)a$ruadaned hr
Caarriy Pared IdentiWitAtNo.(PiN) l ttorda)joe wuh l ttt"XCAC 02C.0100 or~2C.6200 W-it Cosmimon Stawkirds
and 11r4f a cops,of iiris tewrrl7r v bcelr pro%-Iaed to tyre well a►filer.
Sh.l atitnde and longitude in dew/ra{nutest nds-ordecirtud d grem
(&f -ell red,?wit 9.Site diagram or additi+anal aril aetails:
You:nlay use tl t haul:of this page'Xo provide additional+yell site details of well
1* W abandomnentdetails. You►nay'also attach additibaat pages if ttsary
CONSTRUCTION DETAIIS Of WEI.0*)RE NG AIIAI t)ONil) smurnw,INSTRUCTion
:tralrath melt crarzra aetkart fvvvi d(g)Yi av6ilah multiply ityeed ate oy,mhri+'ir vw aupyah*
u s1Lr 4NL Y+tfta ihr arantr cnarcPnvelurnfanarEh�nr�eru,,xm ctiro�rRm}t rut ,imrr_ 10,a,1'or,All 1l+ettsr Submii lliis'li�rrrt Within 30 days of-cotnp3etii]1t of well
6a.Well IDLy:CAT-35 ahmwonrrtcn(-to thefouttwing:
Division of Water RemtireLls,Infi►rnratlrrn PrncessEnd Unit;
100 1617 Afail S�f ce Ccintil,Raleigh,NC -1617
fib.Total well.depth:, __(it.) I 27M
10b.For Inleet(ott Weds: In addition to wading die fondto.the address in 443
above.aim subtitit.one Copy of ibis fatilti%Athiu 30 fts of conlpirtiaa of crell
6c.Borehole diameter:6 (its.) abamontnenl to the follotii ng;
Dh'ision of Water Rtsourres,tindet;ground Injection Conttvl Progtatu.
6d.Water level helow•grpttnd surface: 00 1636 Mall Smicc 66tcr,Rateigit,NC`_2 019-1 b36
6c.Outer casing Ica th(if lmow-n), ffL) We.F'or Wattrx-Sitrtnls A lnicctioo♦Veils: In addition to stilling the form to
the addresses) abase. also Stibmit}etle Copy of this faun within. '41 fts of
coniptctian,of well abatulontnent to the ootmty health deptnrmeut of the county
where abandoned,
df.Innereminotthinys le ugth(if tmow�n):,
i'
Eg.Sawn lent"(ir known):
Form GNr-art North Carotim Deparuu od ofEnr•ironment and Natural Resotates-01vistan of Wat.rRcsntuees Revised Atcpts(2013,

i
WELL ABANDON' IFNT RECORD For ltdeatwlUk ONLY:
7U.form cootie used Far single or multiple vrWs
I.Well Contractor Information: NELL ABANDONMENT DETAILS
t `
Brian Ewing 72..Number of rrclls being,alrandoned: 1
%NTd1'Co11wi6rNz W ftrrv►itlownc7 isorwCl<�Iau�ntnBuefJ,nn fit�il�e Few mfftdnk PlOdf+r or rmn-m�a �iqj* r 14h ONLY -�elli .tt� Skit
� x� a pT�nS`1 etir>*tnrcrerkt4i,!+aumli.viwa�rtt,i,�n c.7xrr�ralvrftt i+,vtfnmc
4240-B
7b.At pootimtite milunte(if water remaining in well(s):.. (gaL)
NC1VellConlradorCemificf im14ninber j
SAEDACCO Inc FOR��`+� R' E1PP1.YN1 TIAS�t11w'I.l'':
Canmpun)lvarne 7e.Type of disinfivont used:
2.Well Construction Permit#:
11Lt#11iwitkabk wellAcraratdv(i:#:Cuurgv,Sr�r"t,J'urrrurce,lifiwiao,rn-)trkmawm 7d.Amount of d3 9nfeYttint u ai: i
3.Well uam(chedrwell usc):
Water 5upph,WdJ: Te.Sealing materials Used(chwl,all ibat apply):
QASricnitnmat ❑Mimidpttl/Pnbluc 0 Not.CcmCnt-art 6d Hsrrt nilc Chips orrl°c[[cts
oCacm thcmurt t7 icacineCooti„a SirpPly} Okc5idontial lltaterSupply(V 1,) E3 Sala!Ctntcrli(foul 13 Dry Clay
❑Irctustriol/Comntcrciai Dltcsidtntial Water Supply(shared) ❑Cbtmcicte Gritmt ❑Drill Cu fings
-13kdrAtiom ❑Speeiahi'Gtoul ❑ tatgl et
hnn-Dater Supply!Nell; 0 Beanonite Slurry 0 6her(expia,in under 79)
OM011itoritt�. ❑lter;o�'�t!'
tnjecct[nn Well: 7f.For each ruaterkil sc(_ceted ab orc.pr b��ide amonot of Pmterials!r�ed:
❑Atlrtifer kechar%r�', ®Griiui 4iBtcr kento ltmion
t7AgmrEfer Stota�t gnd RectAtm ❑Salii ity Bander
❑Agoifei Tta OStb"Hwater Main=
Bentonite.:1501b ,Wtr:gal.
t7Ealmerintental Tecbnotop OSuhsidttmce Conunl 79.Provide a Wiff&-cription of tihc ahiml rument procedure:
CfGeolhennli(Closed Loop) D Tracer
Removed DPT Tooling and abandoned boring with hydrated
®Gaolhemmal(Eleati `olio Rearm) ©OTher( laitlunder.7")
bentonite chips. T
06/25/2022 �'v. ta„s .s E? -LJ
DatC vt'eC[CS).abandonco.
52.Well location: A.U r, 1 S 2l'tn1
2 2
Former Cotton Mill Square Site
F¢CititltiClnrrErNuarte g.Gerti
Facility]TV Certification: InY,_„ y v, r :;� tJrr:
801 Merritt Drive Greensboro, NC 27407 Brian ,EWi n 8/10/2022
Pliysicdt'Addreg.Cifj,and Zip $rt #lais ufC4rti 3cA Wert CAiity9 6w,r r.•;tt 0"ecr u�ie
Guilford 13j,sigrttt{g t&s fnrrer, l hereby certify than the m,!T1Jfsl was(ivwe)ahandoned ire
Carttai� Parcel Ideniiticaiimil4o.(PiN) oteat rAdnee with 114 k7CAC pX.0100 or 3C.0200 Tell Cirstimewon SY tttkrrrls
iwid Mot a coat,af'tlris recar d!ream hE evr prm-ided/n the well ciu4?er,
Sb.Latitude.and langltude in degmeshnlnutcals nds or dtc'I degmu.
(if.:� n(r`td,titre tariku+g is sA6erA) 9.Site diigranm or additional Trrll detalls
You_may tte 1k back of this page to prmide,additional wall site details or wo11
)*' W abandomneni details: You may Also sutach additional poges if necessaw
CONSTRUCTION DI'TAII.S 0114 WELUS)Br ink:ABAN1)at ED SUFMI ITAL INSTRUCTIONS
.tlhstti girtf cntiKirLciinrt rrit�rzl'/€/i/'avaeif�'e9,tr. "FeAr mulfuat�i�r}edirirZ.rx,•roynyn•crtisr'siipfalti .
e elta4NLY 41tA rtx avurr"crarvrnxrtto�t rinaixtarrro�aru. crn trim anRmlt are Grin 10a. For All Wells: Submit this farm within 30 da)'s of completion of wc1l
6L Well ID#•CAT-36 abandonrriciot to the fo9lowing;
Division of Water RImuirms;•Infi rmatio"TPocessing Unit,
6b:Total rill!depth: 77 (ft,) 14517 Afail Scimice Ccftki- Ral".NC 27699-1617
IOlm.For I Ic4tittn Wills: In additku;to mAing the font co the address:in,16a
6e Rambole di9metcr:6 fin.) above;also sntatiia one t of t}mis`Iidnit«titbiim 30"d*,s Of completion of well
abimonmerd to tlto follanving:
Gd F1 atcr lccctbcl 'gruunti st,rfaee ftt) MUM of Water Recourses,Und ftround IriJecdon Control Program,
1636 Mail Scroce Ci 4iter,RaaW,ir,It `2761 -1636
6r-Outer cx.9'Hg len if lmntrn• 10c.For Water.Sunnlr�aC Inlectio l Wt'.1lk In addition to sending the form to
( ) (ft) the address(es) above. also submit lone copy of ibis foini iNithir 30 days of
couiptetiou of well abandonment to i he county hegith°depmnment of the county
6f.Inner tasitionbirig lempth(if tmo"): (ft) j,,-h rc A=oncd,
6F,server[length(if Imowtny (ft) I
r
Fona G%W-10 North CamUm De-p 3nnrnt of ft irooncot and Notmal Resoteccs-Division or WatcrRc uiuccs Revised AuVin-V l3