Guilford_Well Abandonment_20230515

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David Hardy 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well ownerpersonally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed- Indicate TOTAL NUMBER of
2906-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):IV_(gal.)
Aqua Drill, Inc. FOR WATER SUPPLY WELLS ONL :
Company Name 6
7a Type of disinfectant used:_
2.Well Construction Permit#-
List all applicable well construction permits(Le.UIC,Cow*State,Variance,etc.)ifltrrorwr
7d.Amount of disinfectant used: 9 f"'-,7—
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
[]Agricultural ❑Mimicipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
'�
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay r� •.
gin-
❑Industrial/Commercial ❑Residential Water Supply(shared) WConcrete Grout ❑Drill Cuttings �
❑Irri ation ❑Specialty Grout ❑Gravel M q
Non-Water Supply Well: MAY 20
❑Bentonite Slurry ❑Other(explain under 7g) 23
Inje ❑Recovery
Injection Well: 7f.For each material selected above,provide amount off m terel"u
❑Aquifer Recharge ❑Groundwater Remeiliation
❑Aquifer Storage and Recovery OSalinity Barrier N
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7 Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating(Cooling Return) ❑Other(explain under 7g) ��
4.Date well(s)abandoned:
5a.Well location:
Facility/OwncrName Facility ID#(ifapplicable) S.0 fl do :
Physical Address,City,and Zip 2 ✓n� Signature of Certified ell Zan ctor or Well Owner Date
(
By signing this form.I hereby certify that the well(s)was(were)abandoned in
unty Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b_Latitude and longitude in degrees/minutes/seconds or decimal degroos: and that a copy of this record has been provided to the well owner.
(ifwe`ll field,one lat/long is sufficient) / 9.Site diagram or additional well details:
--7 , /5 � N 79)t 0 7�` 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 muldplebjeetionornon-watersupplywells a
ONLYudth 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#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:. 3 e2f (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter. 7-6 C. 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: (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft,) 10c.For Water Supply&Iniection 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): 00 abandoned
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of WaterResources Revised 2-22-2016

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
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 S �,.� I _� � LATITUDE 3____
Well Permit Number: .3]L-)-I, \-J IN 4 R�O O C w LONGITUDE
Well Contractor Company: J"15�,4 a DC-7 Completion Date: S� .
Total Well Depth: ft. Well Yield gpm Static Water Level: ft.
Outer Casing Material: Formation Log
Casing Diameter: 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.
Depth Material Method From: ft.To: ft.
From: ft.To: ft. From: ft.To: ft.
From: ft.To: fL From: ft.To: ft.
From: ft.To: ft. From: ft.To: ft.
Water Production Zones
Depth: ft, ft. ft. ft. ft. ft. ft.
Yield: gpm gpm gpm gpm gpm gpm gpm
Method of Repair:
r r
Method of Abandonment:)�S U A r'► 1 C l� s i ;r����n �S., .� 1 i k
0 ,A{-ram y C;' r![<,'cp
I hereby certify that this well was constructed,repaired,or abandoned according to the Guilford County Well
Rules in effect on t s ate an tMs ras been provided to the well owner.
Well Contractor: Certification#: fJGate:
Record of Pump Installation
Pump Installation Company: Completion Date:
Pump Depth: ft. Static Water Level: ft.
Pump Brand: Pump Size and Rating: hp gpm
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#: Date:.
` i
Revised:January t,2009

�o9°co&. E1i wk anmenW Health MvIsIon Waterf Quatty sect0on
400 W Market St.
Greensboro,NC 27401
(336)641-77613
y
O�y�ALN&�
Permit#: 22-12-WAHR-00058
May 04, 2023
TRENT PRATER
5245 MAXWELL RD
GIBSONVILLE, NC 27249.
Ref: 5245 MAXWELL RD GIBSONVILLE, NC 27249
Dear TRENT PRATER,
This letter certifies that to the best of my knowledge,the abandonment of the well at the property as
referenced above, was abandoned according to the Guilford County Well Rules. The record of
construction has been received and the well contractor has certified that all work was done in
accordance with the aforementioned rules.
The Well permitting, inspecting, and sampling programs and policies of the Guilford County
Department of Health and Human Services are designed to document that the aforementioned rules
are complied with in order to protect the public health and groundwater resources in Guilford County.
Such programs and policies do not guarantee potable water quality or adequate water quantity in any
well.
If you have any questions concerning well rules, the record submitted by your contractor, or how to
test or treat your water, please do not hesitate to contact us.
Sincerely,
Environmental Health Specialist
CC: Property File
400 W Market St#300,Greensboro,NC 274011 [phone]