Guilford_Well Abandonment_20221021 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1, ell Contractor Information: WELL ABANDONMENT DETAILS
to s set\ ,James �tAtr r C' r 7a.For Geoprobe/DPT or Closed=Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on h6%"property) well construction/depth,only I GW-30 is needed Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Num``ber11 11 (� 1 1 �+ 7b.Approximate volume of water remaining in well(s): D_(gal.)
W �` ar C `LXM e. Ft hl,. FOR WATER SUPPLY WELLS ONLY:
Company Name J __� ii
(� /�Q ,A6 {� �1 �� t� 7c.Typeofdisinfectantused:Clf�.�Ae.%11LlPoCVl1tSe. C"�n�Or� L
2.Well Construction Permit#:a g(—iO o—V V IR N 1',"V t5 fib✓ ^ 1
List all applicable well construction permits 0.e.UIC,County,State,Variance,etc.)tf now //(Q a Aces (a can(�(� Cl f
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materiels used(check all that apply):
❑Agricultural ❑ crpal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eside 1 Water Supply(single) ❑ d Cement Grout ❑Dry Clay
❑kndustrial/Commercial ❑Residential Water Supply(shared) tlyl'Concrete Grout ❑Drill Cuttings
❑hri tion ❑Specialty.Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7f.For each material sele fted above,provide amount of materials used::
❑Aquifer Recharge ❑Groundwater Remediation 9wach of C o o Cr�ke—G t'o tAA m',Xe—G
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g Provide e brief description of,the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tm
❑Geothermal eatin Conlin Return ❑Other lain under 7 ) C�N W e—t 1 C ex ��Q 3 1.C:�tJ U_� A ro L\11
4.Date well(s)abandoned: `
®/aoa a Ieock, RarVeA��- �ucK 4 r) eve 11
{I1Ln(JOL�t'� C4t�f.t'e'�C�r0u-4 m•,X t h10 we-0
Sa.Well location:
� �:\1 w et1 C�cv►���ea�al l-from.6c,�ln•-�O�aP
Facility/Owner Name Facility ID#(if applicable) 8.Cerdfi tion:
Physical Address,City,and Zip Iriputure ofCeitifi ell Contractor or Well Owner Date
na.If-ora C.oL\i\k!� S$3�A 33$ By signing this form,I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA ArCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifA.001
well field,one liefttlong is sufficient) r, 9.Site diagram or additional wo".
36o O� t 11D N ("I e "1� You may use the back of this paoe �t t EDI details or well
• - Rr abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)TIEING ABANDONED I T /i 20ZL
SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.Formultiple injection or non-watesupply wells
ONLY with the same constructionlabandamne1ntt)vu can submit one fo+rrt: 10a. For All Wells: Submit Hhj9tRStt�''� ys completion of well
ba.Well ID#• dl 'O�r w of 6 5s-i abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: o (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (iu.) 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: �O (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(If known):un WIX6 W r\ (ft,) 10c.For Water Sunoly&Injection 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
6f.Inner casing/tubing length Of known):AD r noer CQ tfll) abandoned
6g.Screen length(if known): i1) Sr,f t-e r1 (tt.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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