Guilford_Well Abandonment_20230818

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werley 7a.For Geoprobe/DPT or Closed-L lop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GWI.30 is needed. Indicate TOTAL NUMBER of
3344-A wells abandoned: --
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.6 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknoun
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public IN Neat Cement Grout 19 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Cormmercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 70
RMonitoring ❑Recovery �^', /
Injection Well: 7f.For each material selected above,provide amount 0�7;at� s ys" ��J
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite - 20 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier o �3
❑Aquifer Test ❑StonnwaterDrainage Neat cement 40 Ibs PfE'� �LPt�
❑Experimental Technology ❑Subsidence Control
f!P?jOi'e1"�Ivll
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Gravity feed bentonite from 25t-5t bgs
Pour neat cement from 5' bgs to ground surface
4.Date well(s)abandoned: 8/9/2023
5a.Well location:
CBL. N/A
Facility/Owner Name Facility ION(if applicable) 8.Certification:
3200 W Friendly Avenue �` p,�� '�� 8.10.2023
Physical Address,City,and Zip Signature ofCertitied Well Connector o);I ell Owner Date
Guilford. By signing this form, I hereby certify that the wells) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with l SA NCAC 02C.0I00 or 2C.0200 Well Constntction Standards
and that a copy of'this record has been provided to the well owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.087300 N -79.833715 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
Attach well const-tiction record(s)ifavailable. For multiple injection ornon-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (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: 14.87 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft,) 10c.For Water Supply&lniection 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): 10 (ft.) abandoned.
6g.Screen length(if known): 15
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources; Revised 2-22-2016