Guilford_Well Abandonment_20231006 (6)

WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David Hardy 7a.For Geeprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/dgA only 1 GW-3 i is'needed. Indicate TOTAL NUMBER of
2906-A wells abandoned I j
NC Well Contractor Certification Number ?b.Approximate volume of water rei airing in well(s): I � (gal.)
Aqua Drill, Inc. FOR WATER SUPPLY WELLS ONLY:
CompanyName 7c.Type of disinfectant used: J I ( L 7O �/e
2.Well Construction Permit/l
List all applicable well construction permits Ct.e.UIC,Count};State,Parlance,etc.)ifknown
7d.Amount of disinfectant used: ,/Qom'
3.Well use(check well use):
Water Supply Well: 7e.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 CementG iut, _ f a El-Dry Clay
u 4 :"''i °•tl D I;till Cuttings
❑Industrial/Commeroial ❑Residential Water Supply(shared) Concrete Grout g
131rri tion ❑Specialty Grout O C T ® 6 2023 ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery If1;C;T^4';%C� ?r^, 1 t ,.
Injection Well: 7f.For each material seteetedAbve,proUlAmount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation /
❑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) ❑Trncer T f
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g) ��� �b �� Ct
4.Date well(s)abandoned.
G,
Sa.Well location: � sr , d�lleo-1
Facility/Owner Name / Facility lD#(ifapplicable) 8.Certlficatl d:
ell
Ph yst l Addrgs 241d
� Signature of Certified WX Cotcr r Gr Well Owner Date
By signing this Jong,I hereby certify that the wells)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0I00 at-2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 9.Site diagram or additional well details:
3�- N '�� � 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 wellconstructionrecord(s)ifavailable.Formultiple injection ornon-watersupplyuTUs
ONLY with the same constractionrlabandomnent,you can submit one form.
10a.For Ail Wells: Submit this form within 30 days of completion of.well
6a.Well IBM: abandonment to the following:
Division of Water Resources,Information Processing Unit
6b.Total well depth: (ft) 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Injection 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: `t—L) (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 Suoniv&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
6E Inner casing/tubbig length(if known): (ft,) abandoned.
6g.Screen length(if known): (ft.)
Form OW-30 North Carolina Department of finvironmental Quality-Division of Water Resources Revised 2-22-2016

i
i
GTJIUORD COUNT'DEPARTMENT OF PUBIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W_Market St.,Suite 300; Greensboro,NC 2740"
_ Record and Constr°uct6on, Repair, orr_ ;, bEindan�11@fit of a O ago
� 4/ r Address of Well: %�dJ 1 '
� !' f LATITUDE 8
Well Permit Number: Irv< LONGITUDE 2Z,
C
t ll Co
ntractor Company: �/, v��
. Completion Date:��2 z/-z. 3
Total Well Depth:ILL ft. Well Yield. gpm Static Water Level: ft.
outer casmg lKaterial: `��! Formation Log
Casing Diameter: in. Casing Depth: ft. Depth Description
From: ft.To: ft.
1 mer Casing Material: From- ft.To: ft.
Casing Diameter: in. Casing Depth: ft. From: ft.To: ft.
From: ft.To: &
Grout From: ft.To: fL
Depth Material Method From: ft_To: ft.
From: ft.To,--it From: ft.To: i ft.
From.-ft.To- ft. From: ft.To: ft.
From- &To: ft. From: ft.To. ft.
Water lroduedon Zones
Depth: ft. ft, ft. ft.
ft• Ft.
Yield: ft.
gPm bPm -Crpm Win Win gPn►
Method of Repair. 3 %Al�--1 (!� ,-7�� f
Method of Abandonment: �il�®��� �•/�� �j:�� ��,������ ���:���r�(����
I Hereby certify that this well was constructed,repaired, or abandoned according to the Guilford County Well
Rules id effect on this date and that a cop of this record has been provided to the well owner.
Well Contractor: �-�
_ Certification#:2�/_/_21W.Date--
Pump Installation Company: Completion Date:
.Pump Depth: ft. Static Water Level: I &
Pump Brand: Pump Size and Rating: , hp gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on this date and that a copy of this record has been provided to the we]I owner-
Well Contractor. Certification#: J I - Date.
Revised:January 1,2009