Guilford_Well Abandonment_20230602

WELL ABANDON102ENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAH S
David Hardy '
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well ownerpersonally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2906—A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
Aqua Drill, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 21 )/ ^� �®
7c.Type of disinfectant used: /J' !O
2.Well Construction Permit#:
List all applicable well construction permits(i.e.lIIC,County,State,VariaticA etc.)ifkemvn
7d.Amount of disinfectant used:_ f9�
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑hrdustrial/Commercial ❑Residential Water Supply(shared) q-Concrete Lout,: ""? "' ;� ,Drill Cuttings
❑Irri ation ❑Specialtydrotiit�� '° s «lE7)Gtavel
Non-Water Supply Well: ❑Bentonite Slurm}�I I N t 2 Z023 ❑Other(explain under 79)
❑Monitoring ❑Recovery .+ It
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation in;vi- "r 'F`..zi 1, n,
❑Aquifer Storage and Recovery .
❑Salinity Barrier
c.e .. W
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) gTracer
7g.Provide a brief description of the abandonment procedure:
�
/�/ .. --yyam�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) /�r:77 ✓ /�/s - 9 y� /�y�74 ,
4.Date well(s)abandoned_r-- ZI-P,
Sa.Well location: JJ ?
acility/Owner Name If Facility lD#(ifapplicable) TCeytifieafi *
Physical Address;City,and Zip /) Signature of CertiSed we tractor or Well Owner Daze
6..,yBy signing this form,I hereby certifyteat the wells) was(were)abandoned in
Parcel IdeatificationNo.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constniction Standards
Sb,Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
N 7���/�1 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attachw�ellcoastmctionrecoid(s)#favailable.For multiple hyection or non-watersupply wells
ONLY with the same cottstruc[ion/gbaudonmenl,you can submit oneform. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:_ � _fit.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:ZL(in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 00 10c.For Water Suyoly&Iniection Wells: In addition to sending the form to 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 where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (D,)
Foam GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016