Guilford_Well Abandonment_20230807 (4)

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 of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) !'or multiple injection or non-water snppiv wells ONLY n•ith the smue
2480—A consvniction abandonment,you can subinu one form.
7b.Approximate volume of water remaining in well(s): 0'5
NC Well Contractor Certification Number
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: A
q t'�
2.Well Construction Permit#: �
Lisl all applicable well perniils(i.e.Cowin,,State,Variance,Injection,elc.)r/'known //�t� - G
7d.Amount of disinfectant used: ._ w
3.Well use(check well use):
7e.Sealing materials used check all that apply):
Water Supply Well: g ( pp Y)
4sr:.a.
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout ❑ Bentonite ChipS�nr111'' 44
eal
❑ ❑ Sand Cement Grout ❑ Dry(Heating/Cooling Supply) ❑Residential Water Supply(single) D'Clay '�
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RlMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 35 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) El Other(explain under 7g)
Surface completion was removed,disposed of off site,and area restored.
4.Date well(s)abandoned: 6/20/2023
5a.Well location:
City of High Point Kersey Valley MSW Landfill
Facility/Owner Name Facility ID#(if applicable) 8.Certl ation:
3940 Kivette Drive, Highpoint, 27261 f'L 7/10/2023
Physical Address,City,and Zip W nature of Certi ed Well Contractor or Well Owner Date
Guilford 7820432373 By signing this form, 1 hereby certrfjj that the ivell(s) hvas (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.954549 -79.931847 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Auach well cousinicuon records)if available. ror multiple a jeclion or non-water supply.
wells ONLY wiih die saine construction abandrunnem,you can snbmil nne,jornr. I Oa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• GW-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 13.0 (ft.)
1617 Mail Service Center,Raleigh,NC 27699-1617
_
10b. For Infection Wells: In addition to sending the form to the address in 10a
1.0 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: 5' (ft.)
Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Suaoly& Infection 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
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013