Guilford_Well Abandonment_20230807 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lewis Lefever 7a.Number ofwells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple ittiection or non-water supply wells OMY with the same
construction abandonment,you can submit ate form.
2480-A
7b.Approximate volume of water remaining in well(s): 4.5 (gal.)
NC Well Contractor Certification Number
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: f+.
2.Well Construction Permit#:
List all applicable well permits(i.e.('ounh4 State,Variance,hyeciion,eteJ if'known
7d.Amount of disinfectant used:
3.Well use(check well use): n
'yam` J
Water Supply Well: 7e.Sealing materials used(check all that apply): t` ;
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ BentoniQdQPsA'oJ'ke*�t`.�
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
I '
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7C For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 92 Gallons
❑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 Over-drilled well with hollow stem augers,and tremie grouted to the surface.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Surface completion was removed,disposed of off site,and area restored.
4.Date well(s)abandoned: 6/21/2023
5a.Well location:
City of High Point Kersey Valley MSW Landfill
Facility/Owner Name Facility ID4(ifapplicable) 8•Certi c ion:
3940 Kivette Drive, Highpoint, 27261 7/10/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Guilford 7820432373 By signing this form, 1 hereby ceiti!that the irell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.Q100 or 2C.0200 Well Constntetion Standards
and that a copy of this record has been provided to the we11 owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 9.Site diagram or additional well details:
35.955176 -79931686 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Mach well constuction records)if available. For multiple hyectott or non-,rater smtpp(v
wells ONLY with the same construction abandonment,you can submit oneJa•m. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 7'0 Division of Water Resources,Underground Injection Control Program,
(ft•) 1636 Mail Service Center,Raleigh,NC 27699-1636
1Oc. For Water Suaaly& Injection 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
where abandoned.
6E Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Fort GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013