Guilford_Well Abandonment_20230213

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.VV
/artbntractor 1 ormaY : WELL ABANDONMENT DETAILS
-ft7a.Number of wells being abandoned:
Well Contraactorame(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
construction/abandonment,you can submit one form.
3339 �" E€ :-"- 7b.Approximate volume of water remaining in well(s): (gat)
NC 11 Co clot tion}'�,umber ?"`.;�k P L-a V k...,,L.,
/' I , /� 11- -0-5S't. FOR WATER SUPPLY WELLS ONLY:
(/ T l t' (ll rrr t-t-3 1 '- ?On N A-
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: NIA- {",t.. -- fJ
6
List all applicable well permits(i.e.County,State,Variance,Injectidp,'ete.),ifknow'n 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Munici 1/Public *eat Cement Grout 0 Bentonite Chips or Pellets
❑Agricultural � � `' ❑ D Cla
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout rY y
0 Concrete Grout 0 Drill Cuttings
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Gravel
❑Irrigation 0 Specialty Grout 0 Other(explain under
it-Water Supply Well: 0 Bentonite Slurry ( P 7g)❑Recovery
7f.For each material selected above,provide amount of materials used: I
ection Well: � Q ,J. / / Q �1
❑Aquifer Recharge ❑GroundwaterRemediation 30/bs, Itips Jot �'ti (eytteN- 2I135' ! Cd/ote, !Jell t
DAquifer Storage and Recovery ❑Salinity Barrier 1 VI C, WOI -
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer p l a e e, G /v pAc f r 2 r1llv1 E /t? 1d w t /"r y 2'teD/7! 'h
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g)
ikei' yct/� r/� ke// /We/,? Ce,i'e,y/
�3 t you,^ es,r,t' r /;l t /ff
4.Date well(s)abandoned: �' � �� �t�` p �r k � � � ��
Sa.Well location: W ell-A, ti, Lc-' rn lt -,tit iv
.Aci PENN MMniilrAUU(W N Cs- N f h 8.Certi c lion:
Facility/Owner Name Facility IDS(if applicable)
2-O( I iti,(tic!etI i?I r,,,,`r N.t, GU .> // 7-/z—k
Physical Addres,City,and Zip ure of C reified Well ontractor or Well Owner Date
CIA I (P r) 106015) By signing this form, I hereby certify that the well(s)was(were)abandoned in
County T' Parcel Identification No.(PIN) accordance with 15A 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:
35:9 if u You may use the back of this page to provide additional well site details or well
00311 NOi9 Q 1 / f7q W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can.submit one torn:. 10a. For All Wells: Submit this form within 30 days of completion of well
i v -
I abandonment to the following:
6a.Well ID#:
I Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699.1617
6b.Total well depth: � � (ft.)
10b.For Iniection Wells: In addition to sending the form to the address in 10a
(I above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: V (in•) abandonment to the following:
1
6d.Water level below ground surface: d'9 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699.1636
/ lOe. For Water Supply& Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft) 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 abandoned.
6f.Inner casing/tubing length(if known): — (ft.)
I6g.Screen length(if known): I 1 (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013