Guilford_Well Abandonment_20231101

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Ronald F. Barron 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2091-A wells abandoned:—
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Piedmont Industrial Services FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
23-02-WAH R-00175 7c.Type of disinfectant used: oz
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ifknown W e I I S h o c k
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 ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Coohng Supply) eResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑hii ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry a Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
ElAquifer Recharge ❑Groundwater Remediation 1.5Yds Well mix No Flyash
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage NOV
❑Experimental Technology ❑Subsidence Control -
7g.Provide a brief description of the abandgnment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under7 ) Disinfect well and install 1" roll pipe to 108' J
proceeded to place 1.5 Yds well mix and displacing water
4.Date well(s)abandoned: 10-20-23 in well. Filled well to ground surface with well mix.
5a.Well location:
Leaterra, Johnson St LLC N/A
Facility/Owner Name Facility ID#(if applicable) S.Certification:
4321 Johnson St. High Point, 27265 10-20-23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Guilford 169368
By signing this form, 1 hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
80.021583 N 36.040118 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 construction record(s)ifavailable.For multiple injection ornourwatersupply wells
ONLY with the same consiruciion/abandonment,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1 08 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
6„ 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: (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 Suunly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
A of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): N/A (ft.) abandoned.
6g.Screen length(if known): N/A ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

FpRD CpU�T� Environmental Health Division Water Quality Section
400 W Market St.
m • ' �+ Greensboro, NC 27401
[phone]
Fh'EALTHB`� Permit to Abandon a Well
Address: 4321 JOHNSON ST Permit Number: 23-10-WAHR-00175
HIGH POINT, NC 27265
Comments/Specifications:
Punched well to be abandoned to Guilford County Rules
Above Information Certified By: T u J� /v-� �' Date: / Z - Zo- Z
Owner or Authorized Agent
Permit Issued: l-4-eW/&��-P, R E H S Date Issued: 10/20/2023
Environmental Health Specialist
Permits for the Abandonment of Wells shall be valid without expiration.
�&Z
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400 W Market St#300,Greensboro,NC 27401 1 [phone]

Diagram
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Permit Number: 23-10-WAHR-00175
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400 W Market St#300,Greensboro, NC 27401 1 (336)641 -7613