Guilford_Well Abandonment_20240318

-�ELL ABANDONMENT RECORD For Internal Use ONLY:
I;Ny c I I,Cqh ra-ctor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or ell owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
I—Ln
3'a _ wells abandoned: j
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
YADKIN WELL COMPANY INC. FOR WATER SUPPLY WELLS ONLY:
Company Name �y
7c.Type of disinfectant used: Al j&_ JJJ
2.Well Construction Permit k: —Q — WA A n—00-02
List all applicable well construction pernuts(i.e.UIC,County,State,Variance,etc.)ijlmoum
7d.Amount of disinfectant used: -3 O�
3.Well use(check well use): Q�
OAgriter Supply Well: 7e.Sealing materials used(check all that apply):
t
❑A ricultural �
g ❑MMunicipaUPublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well:
❑Monitoring ❑Recovery &6entonite Slurry ❑ Other(explain under 7g)
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑'A'qutfer Rke'atge "" "'' ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage C
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed,Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) rt
V �-
4.Date wells)abandoned:
5a.Well location:
Facility/Owner Name Facility ID#(ifnnnlicable) 8.Certif tion:
Physical Address,City,and Zip l r t
`�'�`'•` Iv L -]j�SJ', Signa Certt I tractor or W.11 Owner Date
County Id By signing this form, 1 hereby cercertifywe
that the 11(s) was(were)abandoned in
Parcel By
No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.iLatitu,de and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner:
(tfw,ell,ield.one lat/long is sufficient)
N 9.Site diagram or additional well details
? , �J W You may use the back of this page to provide additional well site details�o/tote
abandonment details. You may also attach additional pages.if necess2l`y. ' L—D
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED NI�'Y K Z024
Attach well catsimcnno records)ifavoilable. Fornmltiple it jection or non-water supply wells SUBMITTAL INSTRUCTIONS 1
ONLY with the some construction%abandonment,you can submit one form.
10a. For All Wells Submit this form within 30;days of completitr�r I
6a.Well ID#: —� abandonment to the following: �e�Q;y
/ Division of Water Resources,Information Processing Unit,
6b.Total well depth: / 0 2— (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: / �4 (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
6c.Outer casing length(if known): (ft.) 10c.For Water Supply&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 Z
of well abandonment to the county health department of the county where
611 Inner casing/tubing length(if known): (ft,) abandoned.
6g.Screen length(if known):
s
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources N
Revised 2-22-2016