Guilford_Well Abandonment_20221118 (2)

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
r
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III7a.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 I GW-30 is needed. Indicate TOTAL NUMBER of
NC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of watel remaining in well(s): <5 (gal.)
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name 7c Type of disinfectant used:
2.Well Construction Permit Munk
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc.)if known
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 H Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑lndustrialtCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
01tri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
HMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 100 l bs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Coolin Return) ❑other(explainunder7 ) filled annulus with bentonite,hydrated, capped to
match existing
4.Date well(s)abandoned: 1 1/8/2022
5a.Well location: NOV 1 82022
EM 99GRE _.
Ifliviir3«r l . sj t;r:i1
Facifity/Owner Name Facility ID#(if applicable) 8.Certification:
101 Spring Street, Greensboro, NC
Physical Address,City,and Zip tgnature of Certified W ontractor or Well Owner Da
Guilford By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C 0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.073222 N 79.79503 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#• D V V,A,—1 abandonment to the following:
�1
Division of Water Resources,Information Processing Unit,
6b.Total well depth:43 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
i
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.2`,CC (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 ResourcesJUnderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 43 (ft) 10c.For Water Supply&Iniectio n 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(if known):43 (ft.) abandoned
l
6g.Screen length(if known): u n k (fL)
f
r
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016