Guilford_Well Abandonment_20230526 (7)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Kevin White 7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple ityeelion or non-uraler .supple wells ONLY with the sume
construction abandomnetu,von can subnuil one form.
2973
NC Well Contractor Certification Number
7b.Approximate volume of water!remaining in well(s): (gal.)
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: none
2.Well Construction Permit#:
List all applicable irell permits(i.e.C'oun(v,Slate,Variance.h jection,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout 'sue.•ate'" 1ff4eifMjate Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout b DryWy
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout MAY 2 6 Wrill Cuttings
❑lrri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite SlurryInfc, r fCCZj `23'QtUrt(explain under 7g)
OMonitoring ❑Recovery
C NOOCV7
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation < 1 gallon
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer grout in place
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 5/4/23
5a.Well location:
MJM Owner LLC
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
Digita2610 Oakland Ave Greensboro, NC Kevin White Date:1202305.22 ly signed bys5o,O'4'001 5/22/23
Physical Address.City,and Zip Signature of Certified Well Contractor or Well Owner Date
Guilford 235463 By signing this form. 1 hereby certify that the well(s) ,vas (were) abandoned in
County Parcel identification No.(PIN) accordance,with 15.4 NCAC 02C.0100 a•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]at/long is sufficient) 9.Site diagram or additional well details:
36.06230 N —79.83561 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 records)if available. For multiple injection or non-sraler supply
wells ONLY frith the same construction abandonment,you can s,tbtnil one frn•m. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: IVIW-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.)
20 1617 Mail Service Center,Raleigh,NC 27699-I617
lob.For Iniection Wells: In addition to sending the form to the address in 10a
lipabove,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
12.1 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Suouly& Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ftJ 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
6f.Inner casing/tubing length(if known): 10 (ft.) where abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013