Guilford_Well Abandonment_20230602 (6)

WELL ABANDONMENT RECORD For Internal Use ONLY.
1.Well Contractor information: WELL ABANDONMENT DETAILS
®avid Hardy 7a.For GeoprobdDPT or Closed-Loop Geothermal Wells having the same
Well ContmclorName(or well owner personally abandoning well on his/herpmperty) 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 retraining in well(s):
Aqua Drill, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Mine 7-11 /e 11h
7c.Type of disinfectant used: s
2.Well Construction Permit M
List all applicable hell consuracaoa permits r e.UIC,Coimly,State•variance,etc.)if laioIva e�
Td.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement •rout—^a e—r. :p,.Bcntonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout* 4w.'fL-b V M�Q*f'Clay
❑Industrial/Commercial []Residential Water Supply(shared) ($-Concrete Grout
J Ll y r � 20230
o��❑Drill Cuttings
❑hri ation ❑Specialty Grout V 29 ❑Gravel
Non-Water Supply Well:
❑Bentonite S�1�ttzy__ •- ,lgti�lher(explain under 7g)
n'
❑Monitoring ❑Recove
r,3D�;� ; y
Injection Well: 7E For each material selected aI ove,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier —
❑Aquifer Test ❑Stonmvater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure
[]Geothermal(Closed Loop) ❑Tracer � � �
❑Geothermal(Heating(Cooling Return) ❑Other(explain under 7g) �Ly�11111C �i.�!��/` /Utl s�.7len, Re,;z/T7�7,
• L
4.Date well(s)abandoned:.? -23 tl •� / y
Sa.Well location:
Farycility l/Db�(if applicable)
/ S.Ocation
Physical Address,City,and Zip G—'7���G� Signature of Certified Well Contmctor cll 04ner Date
By signing this fonn.I hereby cent that the tvell(s) was(were)abandoned in
un Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or2C,0200 Well Construction Standards
3b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this recor d has been provided to the well owner.
(if well field,one latllong is sufficient)
9.Site diagram or additional welt details:
�,140-r 7N 7� r V j-- `J W You may use the back of this pace to provide additional well site details or well
�" `7 abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUgMI7-tAL INSTRIICTIONS
Attachwelleotisinraloiirecord(s)ifavailable.For multiple bdectionornmt-xmterstipplvwells
ONLYWth the same consttncdoi/abandonment,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:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (M) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For lniection 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: 1 U (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft,) 10c.For Water Supply&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
6f.Inner casing/tubing length(if known): (ft) abandoned.
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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