Guilford_Well Abandonment_20240123 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Blair Mitchell 7a.For Geoprobe/DPT or Closed-LIoop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-3�0 is needed. Indicate TOTAL NUMBER of
N C W C 4419-C wells abandoned:+
I 0
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):_ (gal.)
Redox Tech, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
WI0400608 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)ifknown
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 ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout O Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
IRMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge XGroundwater Remediation Type II/11 Portland Cement —25 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure-
OGeothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Portland cement tremie!grouted from depth to surface
filling well vault
4.Date well(s)abandoned: 1/10/2024 .;
Sa.Well location: n p
TForce Freight
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
4411 Groometown Road Greensboro, NC 27407
ln�/Z 11A 5J202�4
Physical Address,City,and Zip Signature ofCertilied Well Contractor or;WellOwner Date
Guilford County By signing this form, 1 hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.995785 -79.863324 �� You may use the back of this page'
lo 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 or non-water supply 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#:
TMW-05 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 27 (ft.) 10b.For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6c.Borehole diameter: 2 (in.)
Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,INC 27699-1636
6d.Water level below ground surface: 'r16 (ft.) �
6e.Outer casing length(if known): (ft.) 10c.For Water Su ply&Infection 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): (ft.) abandoned.
6g.Screen length(if known): (ft.)
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Form GSV-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016