Guilford_Well Abandonment_20230112

t
i
i( � ��� D(�O111� For lems;ml t7seOtdEY: ^I+I
This fort can be used lbrsingle,or multiple wells H V a 2023
1.'%Vell Contractor laforntation: tiR'GLL ABAtVDONMENT DETAILS 0!At7Frrlas' 1 ?; 'n g;
Un.-4
Relibe17 I if.Clayton,(II 7a.Number ofwells being nbandoned:; Z7%'1`�1�
tVe1ICUnuacrarNdme(oracllo:cnerpusomllpa6andoaiagacdlaaltisRrerpmperty) Tar multiple Injachrratr or nmr-imrar ',srtppir yells ONLY .1rith rile sae n
catstnruian bbandarrtrent,YOU eausvbmitmrafam.
7b.approximate volume of water rcmninin to well(s):
NC Wcli Con=ctorCc&fieariortX=6er
Aqua Drill.Inc. FOR WATER SUPPL"I WELLS ONLY;
Comoarryl\amo 7e.Type ofriis(nfectantused' `���� �✓��
7 - 0C)nC09
2.Welt Constructiou permit fts2_a—t�
List aJJopplteableurlt p antfts(<a Corm:Srata,[rarianea.ItrfecttaL arc)Urb, , 7d.Amount of disinfectant used:
3.Well use(clicativell uso):
bilater Supplyls?/elL• 7e.Scaling materials used(clieclt all that upply).
DAgrieultural OM�,,icipal/Pablic O NeatCementGmut ❑Betnonite Chips orPetlets
QGeothermal(Hcating/CooluiSSupply) l tsidentialWaterSupply(single) Q S dCcmcntGrout ; a Div Clay
Concrete Grout O Drill Cutdags
Oindostrial/Commercial OResidential Water Supply(shared) i'
[7ltri atian O Specialty Grant ❑Gravel
Non-Water Supply Welk O BenteniteSlurry O Other(explamunder7g)
OManitoring ORecovery
7£For each material selected above;provide amount of materials used:
Injection'Weil:
OAquiferRecharge OGroundwaterRcmediation
OAquiferSwcaee and RecOM OSelinityBanier
OAquftTest OStommtmterDrainage ,t
Ofterimental Technolo_q OSubsideace Control IF,Provide n brief description of the abandonment procedure:
OGcothermal(Closed Loop) QTmcer It4e",4"- ��'C ,EG�� y� r � ���ry�,�.4s
13Geothcrmal(HeathidCoolingReturn) i3Other(explain under7g)
_ �`L.rr��SG�/`'C, /°fiGt��'✓ 3 i�JCf`T/f��/�C.v=.•�YCcST�
•LIatetvcll(s)abandoned: -A/ -/ ©'ZlC•�L CrJ��.2�'/
I'
aa.Zl/e)l location:
S.Certification:
FaeiliiyiOwnmtQame Faer�ityR7'�(ifapplieairie) •
Physical Addccss,Citg,aad 7rp Signaarrc ofCatificd lttell Corwaetar I. all t3nmr c
By slgltltlg this fornt,I hereby.eerlY3-that the weH(s)was(were)abandoned in
County PareelideatificationNo.(M) airordancen-idt15,1NC:ICO2C.0100or3C-0200 Well Cow1ruclionSlmrdards
and that a copy ofllds record has h6uprovided 10lire well olrvrer.
56:Latitude and longitude in dedeecslminutcsisecoads or derImaI degcces:
(ifwell Ldd,out Iatltongissaific!eat) 9.Site diagram or additional well details:
Yon may use the back of this page to provide additional wail site details or well
0 abandonmentdetails.You may also attach additional pages ifnecesM.
CONSTRIIC• QN DETAILS OFiYELI.JSIBEING ABANDONED SDBiVtffTAL II+IS:RIICTIOI►1S
Atrach ueR cwtutrnetian recond(s)fatnilable. harmrdtrpJe m�ecaar orltatt-ii7ttersrrpply
�rcJLsONLYuillrtlicmntecmerrruciiauatrarrdo»sif
renyarcaasubmitoueform. 10a.I4or All'Wells: Submit tins form xithin 30 days of-completion of well
abandonment to the following,•.
6a.AVQH M"a
Division ofiVater Resources,3nforotatioa Prncassing Unit,
11617 Mail Servicc.Ccnter,Raleigb,PiC 27699-1617
6b.Total well depth: �� 00 i'
1oh.'For IniectiontYelts In addition to sending the form to the address in 10a
above,also submit one cop}uVibis form vndtin 30 days of completion of welt
6c.Boreltole diameter: jw abandonment to the tolio�vut�
f
Division o€Water Resources,Underground Injection Control Program,
6d.Waterlevcibelowgroundsurface: Z— 00 1636R7a7Servi6 Center,Raleigh,KC27699-1636
tor.For Water Sunnbr Ii inii ct(on in addition to sending the form to
6e.Outer casing length(i[larowu):_ (fel the address(cs) above,also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
tithereabandoaed. j
6F inner casingltel ing length(if imown): ( )

UU11,MKIJ UUUN 1 1 Ut.A,111S.1IVIL"IN 1 UI' 1" LiI-,I-L I I A
Division of Environmental Health.Water Quality Unit
400.W. Market St., Suite 300, Greensboro.NC 27401
Record of Construction, Repair, or Abandonment of a Well
Address of Well: -7� � j: - e LATITUDfE 3 v�"�' r ��� ✓��
I
jI
Well Permit Nuinbcr:
t �-p� " � UE�� LONGITUpE c�`.moo O"� --
Well Contractor Company: Completion Date:il
7'otal Well Depth: -31 fl, Well Yield: gpnl Static Water-,Level: - ft.
Cuter-Casing Material: _ eJl��='' "r Forniat bill Log
Casing Diallieter: L Gs in, Casing Depth: ft. Depth Description
From: fl. To:
Iitner Casing Material: Front: ft.To: ft.
Casing Diameter: in. Casing Depth: ft. From: ft. To: ft.
F ronl: ft-To: ft.
r�rom: ft. To: f! t,
Grout — .
Deptli Material Method From: ll. To:
Prone: ft.`I`o: f1. Prom: fl. To: fl. _--
from: ft.`l'o: ft. Froib: ft. To:
From: ft:1'o: f't. From: ft. To: ft,
Water Production Zones.
Depth: ft. ft. (t. ft.
Yield: opal gpill gpnl gpill chill 9pm gpin
Method of Repair:
Method of Abandonment: 4GC!,J _0G'� ���. ' i'�c`_c='" `' '`!�— ,�—_=' /c' ` r.�r 3
LL
�.-rJ /•''o�,r�r� .��3'X t'1.1rr/.��'�`�J C�'�C:?'ti='�}'� �-r �'I�'��.�C=ii' �`ce..te��i��
I hereby cerliry that this Yell was c0115trUctcd,1-cpaired, or abandoned according to the Guilford County Well
Rules in effect on this(late and that a copy of this record has been provided to the well owner.
Well Go11tl�ictor: .�r- •� �' Certification ff: ?' . Date:
Record of Pump Installation
Pump Installation Company: Conil letion Date:_
1
Pump Depth: ft. Static Wafter bevel: ft•
Puntl)Brand: Pt1mP SI'fe and Rating: hp 6pm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on this date and that a copy of this record has been provided to the well owner.
Well Contractor: Certification If: Date:
F
Revised:November 5,2015

I
f
�'..
f Tom'.�4��l.-� VCt
JwN 1 2 2023
In Lc n r�n ?r�c:,r aF Ur,-,
VY1 LL AJID1suVD®1y1 E-14J1 RECORD EczlotcmalUseONLY_
This form can be used for single or multiple wells
1.Well Contractor Information: ABANDONildEN'E DETAll.S
ReUbt3rl W.Clayton,III 7a.1'dutaberoftvells being abandutA.-
►Ydi CantrretarYame(ar+ce0a+cnarpetsamiiya6amtaeias�+rllanhistherprapetrr) For multiple fnJeulan or aar-irarer srrppiv trells ONLY +dth the sauce
coustrrrchat cbarrdawnm,3M wnsvhmft nncfamr.
2249 A
NC wall can tr"CU66011901tNuNdw 7b.Approximate volume armor simitming to well(s): l yO (gaL)
Aqua Drill,Inc. FOR WATER SMPLYNVELLSONLY /
CampmgNarne la.Type of disinfectant used:
2.WellConstructiontwirflt�:
List all oppliea6lc+cell peradtr r e Coup{};Stale traria=lnfcrct[0&dr)iffirawit Td.Amount ofdisinfectsat n5ed•
3.Well use(checkwall use):
lVatersuppiylVem 7e.Soling materials used(ebedc oll.that applvk
GAgricultund M_���unicipaMblic II NeatCementGmut 0 BentoniteChipsorPeilets
©Geothermal(Rca ftlCooling Supply) C•IResidcntia111Voter Supply(single) 0 Salt d Cement Grout 13 Dm Clap
DindustdollCommercial 01tesidential Water Supply(sliated) Concrete Grout I7 Drill Cuttings
Dhri atiaa 0 Specialty Grout 13 Gravel
Non-Water SuppVWell: E3 BantaniteSl. ury 0 Other(explain under 72)
Monitoring_ ORecovery
Injection lveil: 7f For each material selected above,,provideamotn t ormakrials uscdt
MquiferReciunp OGmundwaterRomediation5-
C1AgdferSmrgtleaadRecovcry OSalinityBarrier
MAqu(ferTest 13 t i materl3raimdee
r
DExperimentatTechnologr OSubstdcaceCoutroi
96.Provides brierdescription of the abaadoatacat procedure:
Meoffiermal(Closed Loop) DTmcer
IIGeothemrat(Headusf oolingRetum) IIOdter(expl2inunder7s)
4.Datewell(s)abandoned:
ao.Woll location:
Facility/Oagacrimmc FadttrymS,(irappncaara) S.CerdGneoa_
t+lry/sic�al�A,ddtass,City.andZip SiScatt a afCcniRcd Well Conroe rNc11 Maw tc
By signing/!cos forni,r hereby eeriify.tlml the wells)was(mere)abandoned in
County Pareel IdeadHcadan No.(PIN) accord=e midi ISA NCi1C MCA*or-2C.0200 Well CoalrucHon Stmtdardr
andllutt a cops,ofd*recordfrasbearprovidedlorhe teell mwei
Sin Latitude and tongitado in degreeslntinutes/secoads or decimal degrees:
(INdlfiddi aaatmltangissat3eiem) 9.Site diagramoraiidirionalwelldetails:
�?�v P'o�o°`✓�Z ' N �1J0'`Od Z.SO�� ll' hanrtdonr use the aentdetliits.You my nt tivi Ott additional pagdc additionales
well site saqdetails or aveR
pt�es ifnecessaty.
CONSTRUCTION DETAILS Q)F,}yELL(S)BEI`fG ABANDOIV M SilBINIITTAL MS RULMO VS j
Attpelr meA cwurraerhrn nua►d(sJ tf mwilab/e hhrmnhipla hrjeettar or not ntnerarrpply
mil�sONLlhrir)etkusaarreaurtrralfata6unrtmraceutyoueonsu6mtronefarm. 10a,Ylor-All Wet 1s: Submit this l'f6rm within 30 days of•eomptedon of•grail
6a.liTcB IN.
abandonmeat to rite followin:
Division ofWater Rcsonrccs,Iafarmation Processing Un%
6b.Tataiivelldepth: 12—`z" (ft.) 161 IVlai!ServiceCen ter,Raldgh,NC27699-1617
i'
10b:Per lniectiou Walls: to adapion to send'mg the farm to the address in 10a
6c.Borehole diameter• �(ia.) above also submit one copy of this farm vfitWm 30 dayz of compledon,of well
abandon amtothefollii%ft
i
6d:QVaterlevci below ground sorface: (MI oflvater Rcsourcc4 Underground Igjccfion Coutru1 Pragwm,
• 1636 MaS Service Center,tialeigh,NC 27699-tG36
6e.Outer casing[engW(lf imatm): fie) 10c.For Water Suon[v&faieeh'a I Wells: to addition to sending the Corm to
the address(es)above,also submit;ane copy of this farm within 30 days of
completion of'Lveil abandonment to the county health depazmrcnt of the county
m tcreabandoned.
GC iennpnndaa/tubian Ieaath ihflmoNlt): (�) .

I
I
I
GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health, Water Quality Unit i
400 W. Market St.,Suite 300, Greensboro, NC 27401�
Record of Construction, Repair, or Atoandonnient of a Well
Address of Well: ��Er�,�Jr i".. //'i'�//L'�i:4j'i LATITUDE 3
Well Permit Number: 2-27- //f LONGITUDE
Well Contractor Company: fi/z-L'Z?t/ Completion Date:
Total Well Depth: / _ft. Well Yield: gpm Static Water Level: ✓ ft.
�G -
Outer Casing Material: �� _ I+orinatiiou Log
Casing Diameter: " h in. Casing Depth: ft. Depth Description
From: ft.To: ft. _
Inner Casing Material: From: ft.To: ft.
Casing Diameter: in. Casing Depth: ft. From: ft.To: ;-ft.
From: ft.To: ft.
Grout From: ft.To ft.
Deptli Material Method From: ft.To: ft.
From: ft. To: ft. From: ft.To: I �ft.
From: ft.To: ft. From: ft.To: ft.
From: ft. To: ft. From: ft.To: ft.
Water Production Zones
Depth: ft. ft. ft. ft. it. ft. ft.
Yield: gpin gpm. gpm gpm gpm gpm gpm
Method of Repair:
Method of Abandonment: J
��-7-�_�� �iL�,,���i��-ll��E�..-<=�� .�E��u�,� � C�,�i��i,��yf�Ems' a"�-J�2J�f• �//C.<�
I hereby certify that this well was constructed,repaired,or abandoned according to the Guilford County Well
Rules in effect on this date acid that a copy of this record has been provided to the well owner.
Well Contractor: State Number: f Date:
Record of Dump Installatioln
Pump Installation Company: Com0etlon Date:
Pump Depth: ft. Static Water Level:
Pump Brand: Pump Size and Rating; hp gpm
I hereby certify that this pump was installed and wellhead completed according toltf}e Guilford County Well
Rules in effect on this date and that a copy of this record has been provided to the 1well owner.
Well Contractor: J State Number: Date:
I