Guilford_Well Abandonment_20230127

wFj.1, AB&NONlliM RECORD F 1;
mdUmONLY:
This fbm►an be wed for single or met%to wdld
1.Wei Cynlraaelr wwwwom
C�Ulf JS► M .7- Fbr '� or a�s+aadrr a Welk a1Bx wo Aw Moo
Won arrivaetarlVeee(�v+eU owner pewdty eb�Oming well on hisRRr property) whMMKyea GUMIe r anopm
Alb.Apprnztmate volmot of 60a rtnrdMsS 1¢wdks): «)
NC Well Comer CedI&AtIon Number q L
S-I M AU•to�j LX1 T (�1 FOR WATER SUPPLY WEUA ONLIA /�
tis�e 7e.Type of dtdnfectant used:
f.1R'i t�slruM PreNit k
Lit t#op"k wep"M IM CM*Raet l9dhoam.veftA OM4 VAWM 7d.Amount of dlddutent tired: _,1 /L
3.Wel ma(etkleltwdl use):
ader 7e.$aaft nanterials used(eheett till tin t ap*)'
OAgriaultutal 0 ta�UPubiie o Neat Can"ant a BentorSte Chips or Peltats
DGw&wmaal(HaetinWCoolin6 Supply) lAAidw i Wa*Supp(y(singte) 13,*d Cement Grout ❑Dry Clay
13bhMVW#CMMCMW OReaideuuW water Supply(shorted) m Cottcretc Grout Cl Dn71 Cuttings
Obrhution Q Specialty Grout ❑Gra►d
Nee-wader Sappfy wdl: o Dentonice Shm E3 Odter(explain under 7a)
amonitaft,- - 7E For each material alsatsd IkM provide aadaut Of Mftrkh met
e :�
❑Ae Whr 00rouidweter Remediation L( -- �� i L.iZ.--
ClAgtdfbr Strorttge and Recovery ❑Salinity Barrier
OAgtefarr Ted 13ft mw=Drainage -
O gwkumW Technology OSubsidenee Control 7g.Provide a brid d ref the t1madwaiNOPSNia
OCnnathenad(Ckwd troop) Cfftac r
DQwftM ► Rerun OOdner lain under 7 � � 0�W�
1.Dare waU(a)abtts*md: 2-
sa,WtB lecutlon.,
x V rJ1^`CG2rrJv
—�--'i 8.CerifHcatlon:
Fedliblowner Name FaeUity IIR(If )
t t Ct.eau zrp s w.n our
By a(gnhrg&a fo n 1 hertrby cw*That the weld we►halt)obwedlomd in
cam PwW We aiRcsHon Na(PIN) aceordow with 1 SA NCAC 02C.0100 or 2C-OM XW QtwtOwc OR Symdatda
and data cqV if th►a record hoe bean lvavlded to 19r teed!OSM
Sb.Lati mk Red bmgkv&in dogrevelab rtWwonds or dalmal degrees;
(ifwLq ikid,om b sufeim) 10 9.Site diagram or aaw"al well detldw
Q z�r y�� �a ���� You may use the back of this page t o lrrovide addidwal Ieell sits dei;ila or well
�']!�� N �(�D r W aan bdonment datnita You taay also athicb edditioe} agesm p if nxmsary.
77
gont►at�r.�r� un�+rmnts
.l"vd aaak wow or►owav
eefk onrva to axe M I yes M afte one jinn. Igo. For All WrJld: Submit this flum within 30 days of compMon of well
6d WO IDS' abandonment to the Mowing:
Division of-Water Resources,labranelen Precudeg Uult,
6b.Total wtt6 depth: fL) 1617 A4a118e*vke Csabx,ikalelg6,WC 27659-1617
10b.Irhrr tatecdmn Wells: In addition to sending the fbrm to the ttddM in 10a
abm"submit one copy of 6c.DardM*dkmeter: (L) abandonment to the following•. dtis ilxna within 30 days of compittdeo of wall
6d.Wale kvd hdew paNd ow bra: f SC Divides of Water Re sea ee,Usrlergreatd Weed u Cnetlyd Prglram,
�L ---.(�) 1636 Mail9ervlce(aWw,,,RakW NC 3709-16M
10e.For Water Sandie!inlecdon W in smon,to Md"ft tblm to
6e.ORtcr aslag k%*(Ubwwy: (D•) the alibi (es) above, also subn'td cme copy of ttds term whhm 30 days of
�! n completion of w it ahaandunment to t 1w Qaunty health department of the MOW
ie i;imown): `� I OL) wises a abandoned.
6t thtver casigibdblydg �(
tt RP Pe lope(if kaGWO 016)
>titree t7W 30
North Cantles Department of Enviro and Natural Reaowas-Division of Water Reso new Reused Aage17013

WELL ABAMQNMM RECORD frorlat rt ivast]t!U.Y:
Mlis foms can be usad i+'or sin*arm**yells
1.wen Cselraaear hlYnm~
10 YY1 1 CM � r 7a.Number of weds bft uMudmill._
won coy eiww"a ee for well oww Porsomm obeadimm{well on hzftr property) For n or nMwserr anppy w k OWL T wo Ik ass
MUt rxwordabMMbeeeat)vu can armmatr mu jibnn.
NC Well COMMO r CKU&Agw Nun q / 'L 7L Approximate volume of water remaining h W110):
SI M weer"or Lit. I T Euen!12 FOR WATERKPP'LY WELL$ONL!A II
tlrsslse I NM 7e.Type of dislalketant used:
1��feMN Pmeitttle
Lmr4P+lt 6v$FPV*A*CM*3ft WMI ��1Ad1�" 7d.Atttount of d dktant need: _l�� .�
3.Wd M(e6sek wall aitta):
W 74,Scalene snaterlals used(cheek all the*app�p
p ppml ❑7�`,`('tatpaUPubiic ❑Nat Comont araut 0 Baaoai%Chips or Pellets
OOsoAterm.1(HonglCoolin6xupply) Q tasideptial Water SUP* 0 Canent Grout p Dry CbY
al DRenidential Wata;Supply(shared) Rf`oncmie Grout 0 Dull Cuttings
p 0 specialty Grout 0 Grad
g Web 17 Bentonite slurry o Odw(explain radar 7g)
7f.For oath emt*Ul selaeted above.provide sumWeFsesta t sraed:
1❑AquWM achoundwaterRemedfedon -� l
CAW&SWOOn and Recovery Osetiniity Barrier
❑A*dhrTed OStamwamt Dminev .
13bTerimatal Tethttoiogy 03ub"nce Contml 7g,Provide a brief description of albandcnsaW proeedVM
oGeodomal(Closed Loop) 0ltacm ))
p Ream OOdrar lain under 7 rV/i ✓UYtt r Ytl --
4.Dak wells)abandoned:
5&Wildlaa&A.. JAN 2 7 2023
A ) - JC ��i'r Ur i
g� FacOhy IDC(if ) S.Certification- Infict a s
Dv.Qi3.
h` t 1 Yr LLlrirJ( f.,� r ✓�
CO.end zip wen comma W- i Owner
61 BY 84pn6t&h Am 11rmo cv*rhat the uolIN was i mv)aba dwd in
0-0 Parcel ldet0loodon No.(PiN) asoa►dm w wtth 15A NCAC 02C.0100 a,2C.OM Wo11 Cmgn l m bmdardt
and that a cape of tole record hunt been 1 nnvOodd to Nk vaU mwrer.
Sk Ldlteda 04 is ftmakdoutesfsetond4 or deelmal degrees;
(iftwg bid,ens 8 SUM0010 9.SW diagram or additioeal woo detift..
.r �y���� You may use tht beck of tbis page to provide additional well site details or well
N i(,�D �, �( W abandonmeru detaita You may Ww amwbr edditioaai petpes if necftmy.
Att &wd al hieft tuOMW r Wry Naft W Ma am
trenrQ11L1'trMllMataar 7s� oaJ 109. For All wells: submit ihiv form within 30 dtrys of completion of well
6a Wal ram / abandonmott to the bUo%v4
Dlvhion of Water Bmoote eo„lahcmda Processing Unk
6k Told well dopy: W 1617 Man gwvke Center,Rald&WC 27SWIG17
lob.Ant Irtettlan Webs: In addition b)sending the brm to the adtimn in l0a
6F bwvb t e dY�er:���) abadsubmit fb� thin f xra within 30 d4ys of caapletim of well
6eL VHaterMwl bebw graced aaslka: /� p,) Dividen of Water Resources,Under LdecNm Con"Prag:am,
1636 Matt Service Cavd mr,RdeW,NC 27619-1636
10e.Far water Supply A idedlon IM In WOOD,b KMW8 rho Am to
6t.Oder wit;hvO(if Imewo): (A.} the address(a) nbova, also attbtnit tint oopy of this form within 30 dgys of
completion of will abandonment to the county ba t department of the county
K leer cadq/tabbtg ks�(ef��)� (ff,) where abandoned.
ft nitse+e bob Of kaowe}: N
Form 0W-30 NL camtina Department olEwArotma of and NatuW Rcso=cs-Division of Water Rese"wo levied Angsst 2013

WELL A QNM RECORD F�Ins:satUdaox1,Y:
no fam wa be well fa stiegio or muitlple wells
1,we CwMw Mr ttdf>snmmm
well Clan I Ulf a(orvies owner pwaWtY abandaift well on hsltrr property) Fbr 600wn or AMV4r rr sq* Vdk al1Lr rrfa At aseee
qaosuar+cdar✓a6atabtrten�You cmt aa6rtt aas�6rst
7b.Approaltnate volume of Watertrsasaidttg In WGIOP fad)
NC wan Castdder Qettincation Number
1 Itb[ 1rryZ Or `T EotJ2FORVATER SUPPLY WMAONLIA
Cbspat> Nssis 7e.Type oidla(ttit etant aaed:��� -�°� /L
3.titri CsaslnetflsaPftsseltle
aw d4vadsl lepl OA CM*&ar.►lktraoti 4MAR IN 1rhm 7d.Amount of dhdnRctant wed:
3.Weil Ilse(91111Awdl M):
SW 7e.Sealing materials used(check A that apply)s
oAvwdww ❑Nast Cam►oat Grout a BwAonite Chips of Paints
00wil atmel(Haatirts Cool ft Sal►) l%"char Water Supply(single) 0�Iw Cement Grout 0 Dry Clay
Ob&MVwADMMcrcw OR eidentiial Water Supply(shared) lyconante Grout 0 Dn71 CuttiM
❑IF 0 Specialty Grout 0(wel
Neesawaw s•:pply Wen: 0 BentoniDe Slurry o Other(mgdain under 7a)
MAGInhaft Clitecovery
7E For eoeb ttabefal taltedsd above prov[O sssaassast of a>uswfab Iesdl:
oA4uUbr Redwp ❑vroundwaw Remeediation -- / — 3 2
p*&$tome and Recovery Osatinily Barrier
DAWAr Test Oftimwater Dunnage .
Mawwi w1w Teduukv OSubsidenee Control 7W Provide a brief deserlptleu of alwadslsam t F Geedtuer
0Caud roai(Closed Loop) a twer
p(WOtbppW OOdw In under 7 y �,, 1•i... ,
4.Dsa WaWs)abandoned: 2- J A KII 9
sa.we8 :
7� a c�ertmaltfaa: DY:aBOG
p� 4iame FaeO[ty IDtl(lf �)
2'
tM,gaiod l City.and Ztpq*M&@,,rCgMw wen coatasoeor o'NM
By s*ft dtrls/am 1 hereby cagy that d w nalfN ws fbarrf abmdsrd ttr
cam Pw:d IdermBcation No,(PIN) accotdwwer with 13A NCAC 02C.0100 or 2C.tIM Nab CanmSIMOete SraaIIIII>de
aW dw a copy of fhta record hmt bm pt vWdsd##Ik VW otwsa
Sb.I. *mk sad lsailitnde is dtRreeafmfnutesdseeonds or decimal dt greear
(ifvadl field,era tW b�cioal) 9.Stu diagram ur addidonal mH detsih:
�y/! ,r I iy 1��� You may use the basic oftlna pop to I�rovide additional won site details or welt
Q t i N b7. ) M (! W abandaament&taita You may alw edtsah additional pages if nstsary.
Aaseb vide aaa.al- Heard__ it Now wo t w M~Arw
near ANL1'MA Of araar Yw trtt adaaAr tna�rM 10a. Blur All wells: Submit fhb fonts within 30 days of completion of well
6a Walt MR /� abandoruaft to the following
Division ofWaterResources,Ishw sdesPrwudag VIA
Sk Told Valli dollik. 1617 Mall Service Clad r,Raiailik NC 2709-1617
10b.Far Irtaetlsn Walla: in additioe to sanding the form to the address in 10a
abOM also submit one copy of this form widdrt 30 drys of canpledon of well
6t.Dtetersie eWtaeetsr:
_,j..� (�) abMdaMM to the fbltowiag:
6L W&W tsvd below g need ss 1111"! g,1 Divisors 1636 Mail Service Grist, 1NC 7ttMI96 ��
des Orur taetrg kagM(if lmowr): (R.) 10e.For wa eft IRWIN� In sddition to eel rho team to
the ati b"3(a) above, ahao submit tine copy of this ibrm within 30 dgys of
completion of w it abandonnam to the county health depanmcut of tt cotraty
where abandoned.
6t leer e�hq/tsbiag lsr�lif haown)n (ft.)
6g.S hab Of l (fe)
Foes(iW 30
North Cardisa Department of EuvLnumcat and Nstaai Reaomm-D"im of Wotan Resolaa s Rev mil Atpal 2013