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Home My WebLink AboutGuilford_Well Abandonment_20220923 (5) WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT DETAILS i Timothy D. Leatherman 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of 2888-A wells abandoned: NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): NA (gal.) Pyramid Environmental and Engineering, P.C. FOR WATER SUPPLY WELLS ONLY: Company Name Calcium H ochlorite 7c.Type of disinfectant used: yP 2.Well Construction Permit#: NA- Unknown List all applicable well construction permits(i.e.WC,County,State,Variance,etc.)ifknown 1 0pounds 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) ❑ Sand Cement Grout ❑Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings ❑Irrigation _ ❑ Specialty Grout ❑ Gravel Non-Water Su 1 �Wll_r `° h�_._it . PP y� :� >.i, n k,$ i— ❑ Bentonite Slurry a Other(explain under 7g) ❑Monitoring ❑Recovery Injection Well: C I_n 2D 2Z 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge J r ❑Groundwater Remediation 3000 psi cement mix with pea Approximately 1.0 cubic ❑Aquifer Storageflndl2ec�V'ecyq rC^.•H�:b7SSAlrltit Barrier El Aquifer Test : "w % o ❑StormwaterDrainage gravel (no fly ash) yards El 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 pea gravel with no fly ash 4.Date well(s)abandoned: 09/1 4/2022 5a.Well location: Piedmont Triad Airport Authority NA Facility/Owner Name Facility ID#(if applicable) 8.Certification: 7614 Bentley Road, Greensboro, NC 27409 - erg, 09/16/2022 Physical Address,City,and Zip Signature of CertifieA Well Contractor or Well Owner Date Guilford 7816911602 By signing this form,I hereby certify that the ivell(s) was (were) abandoned in County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards and that a copy of this 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: 36.113730 N -79.950935 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: 98 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 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: 50 (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.) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 'S`vFORD go Environmental Health Division Water Quality Section c 400 W Market St. p Greensboro,NC 27401 (336)641-7613 i ✓ yA1� P= G�NfALTM&NJ� Permit to Abandon a Well Address: 7614 BENTLEY RD Permit Number: 22-09-WAHR-00009 GREENSBORO, NC 27409 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: r� Own r or Authorized Agent Permit Issued: Date Issued: �z E iron nt He h Specialist Permits for the Abandonment of Wells shall be valid without expiration. Diagram Page 1 of 2 400 W Market St#300,Greensboro,NC 27401 1 (336)641-7613 4 ApproximateNA Location of Septic L4P �It •�� ,I - Supply Well II i i � • �` _ z,��• P'a'�` jt t J r a ` I Ia 14,Bentley Rd } i r: �� ^ 'sue + .i r., , t �� ` � • y�l. - • �' l Approximate Iocation of Septic �,-' ITank , •� + '+'. MIS' .• �� `ty.X _,tr Vit- ` ,�� •�xi ♦ ';X��3,y�rj��••��_:; +5 ,i 4�°:.1 �p`"+i y'•�.,ir,' ++•...ir+ _}•.. - 'Y�1•.sr•]s%*. .`�•v. 1� s- Ss'?i? B`eMeY d ;b•,'�{ p Bentley R• �•� _ �,��`_ - �� - IL 1• ' 1111• 11 Monitoring Well Abandonment Detail for 8-inch diameter borehole with 6-inch steel SW=1 casing to 98 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. 98 Monitoring Well Abandonment Detail if PTAA Property PYFRAM 1 D 7614 Bentley Road, Greensboro, NC Guilford County PIN: 7816911602 ENVIRONMENTAL&ENGINEERING,P.C. I