Guilford_Well Abandonment_20220818 (4)

WELL_ABANDONMENT RECORD For lMerkil Use ONLY:
This fohn can be used for single for mullipte wells
1.Wen Contractnr information: AML ABANDONMENT.DtTA1G5
Brian Ewing 7sL Ntunher of wells heing ahandlie'd:1 _....
1lydrCoulmdnrN2me(of tv-11 aAn r pc rsotnlly.nlusianin.cvcil on h€aA�hr Fw• evrttrpk, utdetw(w or aw rmillrter sirpph wells ONLY wtdh the ".je
pr"y)
` cnebtrrrctare,,4�rulit:urvrac►tt,ertn cwr,rulwit a_vrfnrn�,
4240-B
NGWcIi CLir+irJclarC�ti1'iuilirmMumbtr �+b.Apltivracitn4te vnluitt►:Of�at�r�'ire`ntainin�in nefl(�} _ (�aLi
SAEDACCO Inc FOR NVATF.R SUPPLV ANl LRS QTti.Y:
Conip:tmy Name 7e.Type ofdisinfeetant used:
2.We tt Construction Pccrtnit 4: E
Il+tt�ll s,(P�Picaahhr urllauri,aPsu(i: Lirurrh,Su i�.l'urJruke.lui�cf nn.,�n;) rvwrr 7d.Atnottnt of disinfectant used:
3.�Ve l ust(chedcrrell u )
Water Supply Well: Tr_Scaling mgt+ ialrntd(shoot;Dili that alrply
i7Agt nlhtril 17?,ieotiCipa11P4ibfa .Nextt.Cemcnt fitrtttt IR Bcotoriitc Chips or Pcli ,
130cotherortet(14conse+'Cooting.Supply) McsidCutiat Water Supply(sinele) ❑$grail l tnttgd OW01 ❑Dty Civy
❑lrtctnsfnatlCaimmereial ❑Rc6dentiai%Vater Supgtlg(shared) ❑ C®nctete'Grout ❑ Drill Gutting-.
ofM- tiara p Spwialty Grant ❑ Gmteef
Knn-W r'�appiF Wett; 0 Bentorke Sluay 0 Other(explain under 7g)
❑Mo niiotitqlP . ❑FCtcove '
injection Welt: X For each material selected abo r,provide Amount of.: aterials wed;
❑Agnlfer Rccha e'n ®Grunttde4itter kittetltation
[Aquifer Slotiige and Recoven, b$olineity Barrier
❑M ifet Test t7Sitii itty iter Dr illAge
Bentonite. :150lb ,Wtr:gal.
❑Erp rirnenial Teelmologu ❑Subsit1tweC6twl 7g,Provide a btiiirid cription of the'alrindoummt nroeiAure¢
OCreotheanal(COsedIo0p) I�3racer
Removed DPT Tooling and ndoned ilordxic trtttlt�hydrated
OGeothernral(1leati lCuolirl Return) ®Other.( lafnutrder7 }
bentonite chips.
06/25/2022AUG
4,Datc�rr1(5).abandnncdt A.�.. � -
51.VVelt location: Uni'..
Former Cotton Mill Square Site
Fatitity,�c4•rt�rNumc Fsxiiii,•17,J5 i(atriipplic,ryble}
S.Cerfificallon:
801 Merritt Drive Greensboro, NC 27407 Brian Enri n 8/10/2022
Pltysieai Address.(fit},and Zip `r t}t�ic of Ckiiiied tVc11 Cp,m, tr,r r{'<ti Q,rrer D'At
Guilford I3p•srgnlrw this fiarni, I hem6y c:ert%fy that the shellfs1 wq.v(ieem)aheandoned hr
Loamy Paget identilTcatirmtNo.(PiN) atawrittinbe wah IM liICAC 02t.0107.t r 2C,0200 Midi S5 44i^ki ds
and Nrat ca copy afthis rewrd hm-!acne prcnidedio lhe>tgel?Or ,ner,
Sb:1410014c and fongitudo in[It cstminutcai'seconds ordbe nn21 dq recs:
(ifuttl fled,ofte tatik trg iss,it ieut) 9:Slto diagram or additional well detatise
You:may use Ilia track of this page to ptoc•ide additiorkil well site deans or cvvll
N W abandonrtteru detaiis. You may also aimch addiiionat pages-if necesiam.•
CONSTR1fMON DPT'A1L5 OF W1 L14S)BEING:ARAN60NED SUBAUTTAL ifNSTRUCTIONS
:tUuu�r tired rn2aAatxaWiat rerural(sj`il'rntrlF,r�hde. h'e%r uruhili�l F�cltrare'.rw anrefnzMnr'sttgaPj' i
Welk f1PV y with Ile avurc .(Mtf .0- I ttr. For All %Vcttc: Submit this form nithin 30 days of completion of well
69.Well jD&CAT-37 ab.•endonmcnt to the following:
Division of%later Rm u:rees,Information on PrOtessing Unit;
6b Totai ssvil depth: 77 _fft,) 1617 Stail Scrtricc Center,Raleigli,NC 276"4617
1[Ib.Far Inlesdtin.W ls: Itt additi'en to sending.ire fonri to.the addtirss.io,10a
6c Borehole diameter 6 abotee..also subatit one�pvF of thisiNiu ithfin.30 4's of completion o V411
(In:} abatidorimerd t6 the Mowing:
I
( Water icv'ci hettm-ground surface- Division of Water Resourkes,Underground hijeftlon Conlrbl Program,
163E Mail$ervice Center,lbleigh,NC 274*1-1636
Me-FQr WAter 5119911& lfthsti n��` ilo In addition to sending(be form to
6e Outer caving length(if knr►vra): tom) the`address(es) bmve. also submit Go de-copy of this foeni vvithiti A days of
cornptetion Of urell sbmWonmcnt to the oomtty health department of the county
6t lnrtcrcauinJtnlring length(if I,Ytovtin): (ft.)
vrhers abandoned.
6g,,Sett length(if known). ft.)
Fomr GWI-0 Noah Camilm DepaGrinx rd of Ene iennment-and Natural Resoutees-Dlvisioa of Water Rem Woes Revised Aapsi 2O13

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WELL ABAND.ONXIENT RECPRD FotlyderimlUs ONLY;
This form ran tie used for single or multiple,%tils
1.Well Cantrad'ar Information: WELL ARANbt3NhTENT DETAILS
Brian Ewing 7ti Number of trt�Lqls being abanilan'ed. 1
�V[itCnm ctotidari�iaT rklo rser mnr 41 �I:nafc ninAKtil nn fiCali r For wirltiptc rrrfiecvfar a- rotAiwier " sqp#, tri'fi1s ONLY vtdle else t&jr
t� !".• o pTaP�nY? cor�sRrrcru�v,4nhrurrhaavacret ivevcmrare�i!Ntavi<fann
4240-B
NC Wt10 CorarraorC-ertifrw•-lfaanNurtzbbtr
7b.Appttrximgtc volurne of teat reiinaining is n'd1(*)* (gat.)
SAEDACCO Inc FOR WATER SUPPLV'%NFLIS Oi LY-
Cvatrp y.wautt le.T%Ve of disinfectant used:
2.Well Construction Part i ft:,
Lt#tetttetgnf&rrirh.u if Etrmttk(i.tt Crurrnt Sate,N�rSeP r.Irr}a�ifnn.cat t Jkmawrra X Amonnt of disi.nfectRtft md:'
3.Weil Use(clreck*'el ust):
Water Supply We": 7r Scaling inater9als u i(thockiait drat apply)i
17A r6ratftttr t ❑Municipnt/Ptibl a Not Ccntent.Groult Ifl Rcm6nite Clips or POW
t]t 04kcrtrud(14catincg0co Cling S ly) 13kc5idential%hater Supply(single) ❑SAad Centel l,roul ❑ ih}Ctav
❑lUbOttial/Cammcrtial ❑kcsidentiat%Valet S7rpplh,(sh>rmi) ❑ConMre"Gmvt ❑ 13tm cu:tings
Oitti `tiosi ❑ Spedalty Gtout ❑ Gta�riLi
hnn-Water SUPPt•Well. 0 Bentonite 5lurty 0 Other(explain under 7g)
DMArtitoriiL ❑Tt�;ot �
injection Well: X For each aratcrial cclected above,proAldc amount of:rn_♦lerialsused:
❑Acluiret Recharge, ®Gnnindtrrtler Renicdi&tion
❑Asiirifet Stotage atd Ree&ety [is silitdiy Bardet
❑A uifeiTea ❑St(iruimmerDraina a Bentonite.:1501b ,Wtr:gal.
pEverintenial Twha6logy OS dasittenceC6160l 7g.`Prrnide a liruf dcuription of the abandonment prat r dure:
❑Geolhenaetl(Chased Loop) OTracer
OGeothemral(Head gYAotirl ltetunY) Ot�ther(ea latm under 7 ) Removed DPT Tooling and ando_. d borir}g,-w' hydrated
bentonite chips.
i.'DateR Cl(s)Ahandoncd: 06/25/2022 AUG
Na.Well location: c� fir.^ai��yA� Unit
Former Cotton Mill Square Site `�"' ev
Fa>:efti K?+trrtrNuine Facilhy tDa(Iriappt;uibie) �.Ccrtillcatiaii:
801 Merritt Drive Greensboro, NC 27407 B ri a n E'1fY i 8/10/2022
Pltysiral AAcklmss.Citg,said Zip nl�fitiifiite!Wert 6,t�ClwSf .,x'.ti(hv e 13 qr
Guilford JW.signfrr@'thils t"r}rr+t, I hereby certr,;fy-du#the st.ci`l,(s}was(were)ai ewdoned nr
county Pared Identifleitk"t No.(PIN) t'rccirnldtics with kV ACAC 02C,OI —or 2C.#200 Well atistm a#t+n Raettckrds
and thdf a coptr©f`this record lrua heivir pr mided"to the well owner,
5b,Gatti uftand Innetude in tics/ininutcs/seconrlsordtxnn;l degrem
(ifri¢ll red,one l rtfipag is itffiC civ) 9.Site diagram or addltionat R,011 etalsc:
You:ntay i e ll�ball:of this page to provide additionat well site details or 4mll
N W abandonment details. Yoii tutnl also!atracl<additional pages if neccssm
Ct1i1$TitL,rTioN.i)rTAns OP'VEL14,4�}13It1NG AEliNDONkl) SURAf1TTAL 2STRQCTTOYS
rt(?rtit m;etfi nrzvavctA%en rectordlsl It r+vOlh'e9�- 'f'nr mutripfr"iif}t.Cftrii#ter M7i,�NuPur•wpph�
urfia ONLY*VA rite a�m�-crmvaeetioxsahmt6kurreerir.,i+Jn cnn art wi wte iC.wm 10a.For All Wclti. Suhmil this?femur witliiu 30 days of ceimplctiian of tivrU
CAT-CAT abandonntcnt tothe foflowine,
6a.Well ID#•.
Dlvislon of Water Ret iurtfs,Inform ion•Prbeesging uv t,
6b Total aril depth: 57 (ft;? 1617 tlfailSciralce 61ittcr,Itale`o,NC 276994617
10b.Far InlectlOn.Wetgr hi add6on to sending the form to the addtrss ttt 16
bt Borehole diameter.6 above,aim,subfi it"one bops'of tbis tot n mitliiit 30'divys of completion of tmll
qir) abandonntcul to the fntlttti=ilkIg
64 Water level bcln,%- (ft,l Dhviston of Water Resoutrees Undergroupd Injection Control Program,
giaund sitrfacc: igh,NC Z?f�rt44636
1ti36 Ai.ail Sr�•iet Ct;rttcr,hale
lot For"Watcr.5trnrah.&Infcxtioin Wells: In addition to sending the form to
6c.Outer casing Icnob(if known): A) the addresses) above. also submit{ohe copy of this fermi milhin 10 days of
comptction of well abandonment to'the county health depannient of the courtly
6i Inncrcaiinxknbing ttmgth(if known): (fr.)
titir abandoned.,
Fomr G1l1-30 North CamUna Dep<giaxot.ofPndmnrncnt and Natural Rcsm cs-Di+isEnn aP W'-rlttsoitries Revised Artgust M3
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