Guilford_Well Abandonment_20221216

WELL ABANDONMENT RECORD For Intend Use ONLY:
1.Well Contractor Information: „ , WELL ABANDONMENT DETAILS
Russell James Turner '` 7s.For GeoproIWDPT or Cktaeb•Leop Geothermal WeOa 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
2448-A wells abandoned:
7b.Approximate volume of water remaining In Wallis): a t
NC Well Contremr Certification Number �+ FP g �')
R.J. Turner Well and Pump, LLC. FOR WATER SUPPLY WELLS ONLY: c�rgn�elar
Company Name ,\ �� ��tt �tlr•�r CC`1\6r e-
ff�� 7e.Type of disinfectaat asM:�GoLn
2.Well Coustruetlos Permit 0:a),-'1-U)Tl N R-OOO s L'1
Litt all applicable well oonraucnon permfis(.a.UIC Cou".Sude,Variance,ere.)Ifbmwn
79L Amount of dMnfeariat used; OU
3.WeR ate(check well use):
Water Supply Well: 7e.sealing materlal mad(check W that apply):
❑Agricultural ❑/Iv{a�eclpaVPublw _❑`Nat'Cement Grout ❑Bmmttite Chips or Pellets
❑Geothermal(Heming/Cooling Supply) QRardentid Water Supply(single) * na Cement Grout ❑[ley Clay
❑bwusuuvcommrxcial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
ohnization ❑specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bento tote slurry ❑Other(explain under 7g)
ommatorms ❑ltdcovery
Injection Wen: 7E For such materr-We�aekpted above,provide amount of material used:
❑Aquifer Recharge ❑Groundwater Remediatian y U Qr Q O T �(,it1 / C(�M�n Q rOIA (1'�•X
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwarer Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief descriptions of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer❑Geohermal(Heating/Cooling Return 00ther lain under 7 CkA 1CUG\U'rjnL'o,r--G q f�- '0 IOW Q f-O u r.C
6.Date well(s)abandoned: o "a-70D'), V>ac lee.C7 Ce mee,A� 1euc-\\ I .
NO We \\ Gn�
1\e (j)C\(-�roc, 160AA0m AC A09 LI3ek�
s. Well location: r�� %CPrT,e IL)I- MA �c{gCA-
Facility/Owner Name FacilitylM(ifapplicable) S.Certi don:
?y0o5rn4rr,r�tiQ,ueRb• Gf�„f;boro N•C, a7455 le?�a 2o�2
//Physical Address,City,and Zip G r� Iparure ofce ifiw l Conmsacn w we er Data
l�J U,• \CIJrC COLArYk� 7`65iag3,77 30 By signing this form, 1 hereby certify that the wrell(s) was(were)abandoned in
County Parcel Identification No.(FIN) accordam;e with 15A NCAC 01C.0100 or IC.0100 Well Construction Standards
5b.Latitude and longitude In degreealminutes/tecoods or decimal degrees: and that a copy oJ'this record has been provided to the well owner.
(if well field,ore laubng is sufficient) 9.Site diagram or additional well details:
'U. \\ (qq N 'N, %30 \(o 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 DCTADS OF WELLS)BEING ABANDONED SUBMMAL INSTRUCTIONS
Avarkwellcnnmxctionrmrd(s)ifasalable. FormulWeinjecnoxoraon-wnKrsupplywcils
ONLYwdth de aurae consoacaoWabandonment,you cassubma ooefarm. 10s. For AB Weal: Submit this fora within 30 days of completion of well
6a.Wed ID#: abandonment to the following:
— Divides of Water Resources,[&formation Processing Udt,
6b.Total well depth: ((t) 1617 Mail Service Center,Raleigh,NC 276994617
5 lob.For Indeetiots Welk: In addition to sending the farm to the address in 10a
6a.Borehole diameter: . (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: c� C/ (ft,) Division of Water Resources,Underground Injection Control Program,
�I 1636 Mail Service Center,Raleigh,NC 2709-1636
6e.Oster ending length(If(mown):t I(1 V%Q OW'rN (ft.) 10c.For Water Sandy&Infection Wells: In addition to sending the fora to the
address(m)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
6L Lner tadog/tubisg length(if Interim):nD,Aner 2—$(W) abndorred.
6g.garnets length Of known): n o 5 C rL a r` (fL)
Form G W-30 Noah Camlim Department ofFnvhonmeoW Quality-Division of Warn Rawness Reviaed 2.22.2016

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