Guilford_Well Abandonment_20230602 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAIL
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) 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 Type .11
7a of disinfectant used.
2.Well Construction Permit#/:'
List all applicable well consimctionpemlits ree.'UIC County.State.Variance,etc)rflomwu C,
7d.Amount of disinfectant used- iJ � r2
3:Well use(check well use):
Water Supply Well: 76.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 Great— s'''''; lq�y flay
g_ru:t
❑lndustrial/Commercial []Residential Water Supply(shared) El-Concreto Grout ''�'a ��' r-4 ITMHFCuttings
❑liri ation ❑Specialty Grout I Q�ravel
Non-Water Supply Well: ❑Bentonite Slurry J U N V 2 20 L
❑Monitoring ❑Recovery rry ❑Other(explain under 7g)
Injection Well: s.,-�
7f.For each mate�Itll'Sol"eeie nvprprg.vide amount of materials used:
[]Aquifer Recharge ❑Groundwater Remediation a `'�"
[]Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Tcst ❑Stormwatcr Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure.,
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned''6,7 S
5a.Well location:
1�, 7
acility/owner Name Facility ID#/(if applicable) 8 rtific&* n: -73
Physical Address,City,and Zip 23
� / '' t�G' S nneo el na or or
Date
� o By signing this form, ltet eby certify that the tvell(s)cores(were)abandoned in
ounty Parcel Identification No.(PIN) accordenwe with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy ofthis record has been provided to the well owner.
(ifwelt field,one latilong is sufficient) 9.Site diagram or additional well details:
,r �!r N ��[ You may use the back of this page to provide additional well site details or well
7T . Wabandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMIT TAL INSTRUCTIONS
tittachtvellconsirnctionrecord(s)ifavailable.Form n
ithiplei4ectionoron-wwtersapplvivells
ONLY with the same conslructionlabandonmen4 you can submit one form.
10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
G, Division of Water Resources,Information Processing Unit,
6b.Total well depth:__ , / (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Inieetion Wells: In addition to sending the form to the address in 10a
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: 4L6 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Inieetion 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
6E Inner casing/tubiag length(if known):. (ft) abandoned.
6g.Screen length(if known): (ft.)
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Farm GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016