Guilford_Well Abandonment_20230526 (10)

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) !'ar• nudliple it jection or non-nrarer• supply wells ONLY frith the ,sane
2973 construction abandonment,you can submit one(orm.
NC Well Contractor Certification Number7b.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.County,State,Variance,Injection,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 ZI Neat Cement Grout _ _❑ Bentonite Chips or Pellets
❑ Sand Cemen ro C' `' 'r�^�b Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) r� '�,,,vp,< J„a w,�rY Y
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout MAY 2 6 2023 ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
Inf,rr
OMonitoring ❑Recovery tjhs,
Injection Well: 7f.For each material sel 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) g•Certification:
2610 Oakland Ave Greensboro, NC Kevin White ,Digitally signed by Kevin White
Date:202305.2209:51:13-04'00' 5/22/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Guilford 235463 By signing this form, I hereby certify that the 1ve/1(s) lvas (were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0/00 or 2C.0200 Well Construclion Standards
and that a copy of ibis record 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:
36.06194 -79.83557 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple it jection or non-water supply
wells ONLYwith the suite cons•irtrclion,nbetndomnent.),oti can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
IVIW-7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Iniection 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: 't (in.)
abandonment to the following:
17.3 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 Supply&Iniection 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 county health department of the county
6E 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