Guilford_Well Abandonment_20230602 (2)

WELL ABANDONMENT"COP.D For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David Hardy 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property)i 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 vvell(s): _(ga4)
Aqua Drill, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name .21 /r0 O1h
7c a of disinfectant used: _
2.Well Construction Permit M
List all applicable hell coyntructioupermus(r.e.UIC,Carroty,state variance,etc.)iflmmm 25
,r�
7d.Amount of disinfectant used: �J
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout _ _ ❑Ben-toonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Gro tt ! " a ` ^ I Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) l Concrote Grout i 4w 'n 0 DrillCuttings
❑bri ation ❑Specialty Grout J U N r d 203Grave1
Con-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery 4: .n Pmr!55mi£-,'J 1.;Oy
Injection Well: 7E For each material select0i;ilYty i0ivide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation � a
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwatcr Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(HeatinglCooling Return) ❑Other(explain under 7g) -� F>:d G//�i� �.�0/��" ��'41 ii7,61nal 7
4.Date well(s)abandoned.1 '-23 X- s /
Its? i r-m ( C- �Y�i e,-"Zjj
5a.Well location: �
facility/Owner Name Facility ID#(if applicable) 8. "fic0tion:
physical Address,City,and Zip 7/i_/!I Srgoatum of Certified 1l Contractor or Well Owner Date
iy �' ' t `r L� By signing this fonn,.1 hereby certify that tire rvell(s) was(were)abandoned in
umY Parcel Identification No.(PIN) accoidance with 15A NCAC 02C.0100 or 2C.0200 Well Consintetion Standards
5b:Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy ofthis record has been provided to lire well owner.
(ifavell field,one latilong is sufficient) 9.Site diagram or additional well details:
f/W, .7 N 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
dttaclr well coustrttction record(s)lfavailable.For rnultipleir jection ornon-watersupply wells
ONLY with the same corstructionlabmrdonmeat,you can submit oueform,
10a. For All Welts: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth: 6� (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in I On
6c-Borehole diameter: (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): (%) 10c.For Water Sunnly&Injection 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
6L Inner casing/tubing length(if known): (ft) abandoned
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016