Guilford_Well Abandonment_20230526

WELL ABANDONINIENT RECORD ' FarintenudUscONLY:
This form can be used For single or n»iltipte«'ells
1,Well Contractor Information: WELL ABANDONhIENT DETAILS
I
Scott Hunt, Jr 74.Nu nherof hells being abandi"ed: 1
%Vdt'Conuaclor Name(orrr�ll owner personally a4ndallin;ecli.an Iiisilwl-property) For aadbpie 6 fcei(wr or mou'lr r(cr• supply xirlis ONLY with iN swie
' c•�x+sfrrrctta,irbaxlarr�,�rf,,lv,uccor,sNtu,urarejornr. - .
4561-A
NC Well CanlydgorCcnl6citimNuinber
7b,Approximate volume of ri:A6.retit:tining in ivr:ll(s)3 0 {gal)
SAEDACCo Inc FOR WAIF R.SUPPLY NVFLLS ONLY:
Company Name 7"Type of disinfectant used:
2:Well Construction Permit k:,
Lila ddl np1lhub1 itwIl peritemy(i,e.Ctut ,Sr..Y.!,lliria e,h6reciri,re,elc)t fkwt*v 7d.Amount of&-infectant nsrvl•
3.Weil Use(ebedc well use):
Water Supply Well. 7e,Scaling materials.used(checli all that apply):
p�sricuihtiat QN[unicip.•IVPublic M Ncat Ccmcptdieotrt '. :y _t �'Q,l3craonite Chips or Pellets
❑Geoihcnrml(Heath Cooling Supply) ❑Iicsidcntial%Vater$i uppiy(single) ❑Sand Con U d,ttut�-t �' '"''t�Dry Clay
❑IvdusniaVComntcFcW ❑Residential%Voter Supply(shored) ❑Concrete Grout ❑ Dri11:CuUinds
Specialty GroutMAY 2 ZQ23
❑S ❑Gravel
❑Irri •lion Pe' Y
Non-Water Supply Well: 09 Bentottite) itt g.t rar5C3e+S". U�biher(explain under 7g)
L9Maniloring ❑Recovery
Injection Welt: '7r.Far each tttateri;d selected abGve pioside atmotint of.tmiterials used:
❑Agnifcrliectratgc ❑GroundttrierRememUrUiou Neat Cem.:2501b ,Wtr:20gal. Sand Cem.:lb ,Wtr:gal.
13Aquifer Storage aril Recovery OSalinily Dander
Bentonite.:21b ,Wtr:gal.
❑Aquifer Test ❑Stonmsater Draigwgc
❑Expniuterual Technology ❑Subsidence Control 7g.Provide a brief description of the abandntrmct4rocedure:
❑Ge+olhemnnl(Closed Loop) OTracer
Tremie grouted well from bottom up
❑GeothemiatdieatiamCootin&Return) ®Othcr.(e lainunder?$)
4.Datewclt(s)abandoned: 5-11-23
5a.Well location.•
Motiva
FacilityXhvwr Natw Fa:ilily IDN firbpplicablc) S.Certification:
101 S. Chimney Rock Rd. Greensboro, NC 27409 �� '5/14/2023
Physical'AddrCs.City,and Zip Sialtirtltt of Cin!Gold Well Co t . tor or Wcll Orsnx Diuc
Guilford By.signing lies form, I Iremby certify that the well(v)tuns(here}abandoned in
Cauoly Parcel Idaatift611m No.(PIN) occonlniue i rith 15A,C�1C 02C,0100 or 2C.0200[Mull Cunstniclion Shin(kirds
and drat a copir ofli is record has beers provided to ilia trell on-n r,
Sb.Latitude and longitude in dcgrecsfutionutea/seconds or decimal dcgram
(ifn-cll 114W,ow 4itilong is sitfriciety) 9.Site diagram or additional well derails:
You ivay use dle bacfi of this page to provide additional)vell site details or well
1� W abandounteta details. You may also:Mach additional pages if necessary.
CONSTRUCPION DETAILS OF WELLS)BEIN(.ABANDONED SUBNTiTTAL TNSTRUCTTONS
:lfrarir full cr,rzrrruclhirt racr,rd(s)Jf•ovw1able. Fur nw tiple geetiort or ta,nntxtr&supply
wells ONLY udrlr rl,r smite•rv,rsrrrarrrwr arirvnha:�naar,r un eon s,dmit a,rr four 10a. For All Wells• Subunit this farm within 30 daps of completion of aril
God.Well ID#:MW-2 abandonment to the followinG:
Di}isinn of Water Resources,Information Procmin g Unit,
Gh.Total well depth: 24 I617 Mail Service Center,Raleigh,NC 27699-1617
(ft.)
10b.For Inleyilnn Wells: Ill addition to sending like fore to the address in 10a
Gc.Borehole diameter.4 (in.) abor'e,also submil one copy of this form within 30 days of completion of►veil
abondamrielu to the following:
Gd,Water level below ground surface: 3.5 (ft.) Division of Water Resources,-Undergrou-nd Injection Control Program,
1636 Mail Scriiee(enter,Raleigh,NC 27699-1636
Ge Outer casirt Icrt (if l lOc.For Water Snooty ISTuierrt��YeDs; In addition to sending the form to
�( moirn): (fit.) the addresses) above. also submit one copy of this form within 30 days of
completion of well abandownent to the county health depanmcid of the county
6E Inner casin• tuhing length(if tmawn)h (ft.)
whuc abgndoncd,
Gg,Screen length(if!mown):
Fenn GW-90 North Carotim Deponmcni of Enviromnent and Na umt Rcsotuccs-Division or Water It6ouln:s Revised Augur 2013