Guilford_Well Abandonment_20230526 (11)

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 ntttlliple itl ection or non-haler supply mells ONLY with the saute
2973 cotnsn•uclion abwtdonnertt,t•oa can.submil one form.
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
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.Comt(x State,Variance,hileciion,etc)if known
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 G out: f 7: %• yP'•• Fri Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 77 Drill Cuttings
❑Irri ation ❑ Specialty Grout MAY 2 6 20230 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
�.:.
❑Monitoring ❑Recovery Ifh`G;`r':��=�'�� f....,•„,:31.lr­�
Injection Well: 7f.For each material sele(:jkU',VOV0,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation < 1 gallon
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑S tormwater 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) S•Certification:
2610 Oakland Ave Greensboro, NC Kevin White )Dae:2023o5�y 95230-0;'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 ivell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 NCAC 02C.0100 or 2C.0200 6Vell 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 lat/long is sufficient) 9.Site diagram or additional well details:
36.06203 -79.83466 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
Anach well construction records)if available. For tnuhiple injection or non-crater supply
wells ONLY with the same construction abandonment,yotu crnt snbmil one fr rtn. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-8 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
IOb. 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: (in.) abandonment to the following:
18.1 Division of Water Resources,Under-round Injection Control Program,
6d.Water level below ground surface: (ftJ 1636 Mail Service Center,Raleigh,NC 27699-1636
1Oc. For Water Suualy&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 county health department of the county
6E inner casing/tubing length(if known): 10 where abandoned.
(ft.)
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