Guilford_Well Abandonment_20220923

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: W n a"v. �•;'`°, WELL ABANDONMENT DETAILS
Timothy D. Leatherman �•{ ���' m 4 6 y� `"�
� " 7a.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandorling v llgn lfls/hnr z-ty) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
2888-A NA
NC Well Contractor Certification Number 76.Approximate volume of water remaining in well(s): (gal.)
Pyramid Environmental and Engineering, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium Hypochlorite
7c.Type of disinfectant used:
2.Well Construction Permit#: NA- U n known
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknosm 1.0 pounds
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) O Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
.❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry S Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
El Aquifer Recharge ❑Groundwater Remediation 3000 psi cement mix with sand(no fly ash) Approximately 1.0 cubic
[]Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage yards
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Direct pour 3000 psi cement mixture with sand with
no fly ash
a.Date well(s)abandoned: 09/15/2022
5a.Well location:
Piedmont Triad Airport Authority - NA
Facility/Owner Name Facility ID#(ifapplicable) 8.Certificatio
6823 Pepperdine Rd., Greensboro, NC 27410 09/16/2022
Physical Address,City,and Zip Signature of Cer[ ed Well Contractor or Well Owner Date
Guilford 7826259950
By signing this form,I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy ofthis record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.125923 N -79.937635 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment you can submit one form
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 64 (ft) 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 to 10 (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 30 (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): NA (ft.) abandoned.
6g.Screen length(if known): NA (ft.)
Fonn GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

ORD COVhT�
Environmental Health Division Water Quality Section
400 W Market St.
ti • 0 Greensboro,NC 27401
[phone]
O'�hEq�TK&�J Permit to Abandon a Well
Address: 6823 PEPPERDINE RD Permit Number: 22-09-WAHR-00008
GREENSBORO, NC 27410
Comments/Specifications:
Existing drilled well to be properly abandoned by Certified Well Contractor according to Guilford County
rules.
Well contractor to schedule required inspections.
Above Information Certified By: Date:
Ow er or Authorized lent
Permit Issued: k# ate Issued: ^z
/Envi(onrn;pff1jValth Precialist
Permits for the Abandonment of Wells shall be valid without expiration.
Diagram
Pagel of 2
400 W Market St#300,Greensboro,NC 27401 1 [phone]

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Monitoring Well
Abandonment Detail for
8-inch diameter borehole with 6-inch steel SW-1
casing to 64 feet
Surface
Well Fill Material: 3000 psi cement/.
pea gravel.mix (no fly ash) 6-inch steel casing cut-off 3 feet below ground
surface
NA ft.
64
Monitoring Well Abandonment Detail
PTAA Property
6823 Pepperdine Rd, Greensboro, NC
PYRAM 1 D
Guilford County PIN: 7826259950
ENVIRONMENTAL&ENGINEERING,P.C.