Guilford_Well Abandonment_20230526 (9)

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 Iris/her property) For multiple h jection or non-,rater supply wells ONLY with the .same
2973 construction abandonment,yott can.suhnrii ore 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 well permits(i.e.Coaniv,State, Variance,hniection,etc.)ifknoam
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 0 Neat Cement Grout _ ❑ Bentonite Chips or Pellets
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply single ❑ Sand Cement Gfodt T r t.[l;Dr}(Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 0` ill Cuttings
❑irri ation ❑ Specialty Grout MAY 2 6 2023❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slum ❑ Other(explain under 7g)
ElMonitoring ❑Recovery
injection Well: 711 For each material selEct&fa(i0Q,"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:
2610 Oakland Ave Greensboro, NC Kevin White oae Ily signed by Kevin202305.220950:3-04'00' 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) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 NCAC 02C.0100 or 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:
(ifwell field,one[at/long is sufficient) 9.Site diagram or additional well details:
36.06190 N -79.83608 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
Match well construction records)if aradahle. Far mu6iple iniection or non-waver supply
wells ONLY with the some construction ahandonnnent,you can submit one form. 10a. For All Wells: Submit this torn within 30 days of completion of well
6a.Well ID#:
MW-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.)
20 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For infection Wells: In addition to sending the form to the address in 10a
1 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: �r (in.) abandonment to the following:
158 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 Sunoly&injection Wells: in addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the comity 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 orWater Resources Revised August 2013