Guilford_Well Abandonment_20230526 (8)

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 ofwells being abandoned:
Well Contractor Name(or well owner personally abandoning well on hisAter property) hlor ntulliple it jection or non-crater supply hells ONLY with the same
2973
construction abuttdoninetu,you can submit one form+.
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 ire/1 permits(i.e.County,Stale, Variance,injection,etc)ifknowu
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 Rl Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Gtgsut trr.91.P. Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ~°'-- -� — `� 5�", Cuttings
❑Irri ation ❑ Specialty Grout MAY 2 6 202 Gravel
Non-Water Supply Well: ❑Bentonite Slurry Other(explain under 7g)
❑Monitoring El Recoverylnr.,.ng„�v_.-_ (l
Injection Well: 711 For each ma �taf serecTg�l,abQYe�pr8'at e'4rrrlt�unt of materials used:
r:1�1'J �i
❑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) g•Certification:
2610 Oakland Ave Greensboro, NC Kevin White l- Date:1 02305.2209ly signed by 5oz-0'400' 5/22/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Guilford 235463 By signing this farm, I hereby certify dial dhe wells) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this retard has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.06242 N -79.83507 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 hell construction record(s)cif available. For nndliple infection or non-crater supply
irells ONLY frith 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[D#:
MW-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:
25 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
lip above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
2•8 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 Suonly&Injection Wells: in addition to sending the form to
6e.Outer casing length(if known): IftJ 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
6E inner casing/tubing length(if known): 10 (ft.) where abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environment and Namral Resources-Division of Water Resources Revised August 2013