Guilford_Well Abandonment_20230526 (14)

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 inulliple it jeclion or non-wafer supphv rvelLs ONLY rvidr the save
2973 consnwciion'abarrdonnrenl,you can submit one for•ni.
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 permius(i.e.Coun(v,Stale, Variance,bjeelion,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 9 Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal((Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Gr tr: - SFL Dry.Clay
i
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout >ilj'Cuttings
❑Irrigation ❑ Specialty Grout Gravel
Non-Water Supply Well: El Bentonite Slurry MAY 2 6 202R Other(explain under 7g)
❑Monitoring ❑Recovery T-, a tirtf ,ic r%4
Injection Well: 7f.For each mat�})31'$el'e'r i�i��uSVe prdchd�)ainonot 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 DDae:2023A9 22 0Kevin
51 55m-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) ivas (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 lat/long is sufficient) 9.Site diagram or additional well details:
36.06169 -79.83598 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 we0 construction record(s)if available. For nudliple it jeclion or non-wales supply
wells ONLY u-ilh the same corrslruclionmbandonmenl,you can submil one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well[D#:
MW-10 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 5 (ft.)
lob.For Injection 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:
16.3 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 Surmly&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
6f.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 Natural Resources—Division of Water Resources Revised August 2013