Guilford_Well Abandonment_20240318 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis 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 I GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): ~2.5 (gal.)
WithersRavenel, Inc. 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.U!C 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 @ 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
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
@Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation —80 Ibs Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
~20 Ibs Grout
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7 ) Bentonite was placed in one foot lifts and hydrated until
one foot from top of casing. Remaining space was
4.Date well(s)abandoned: 3/8/2024 capped with grout to surface grade. Flush-mount protective
sa.Well location: manway was filled with grout to surface and covered.
Chandler's Produce& Gas 00-0-0000009972
Facility/Owner Name Facilm ID#(ifapplicable) S.Certification:
5436 North Church Street, Greensboro, NC 27405 3/12/2024
Physical Address,City,and Zip Signature ofCcitified Well Contractor or Well Owner Date
Guilford 7868767393
By signing this form. /hereby terrify 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
and that a copy ojthis 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:
36.1829600 -79.7873870 N You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional egestf necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS t S t �j J"'
Attach well construction records)ifarailable. For multiple injection or non-water supply wells 4' E D
ONLY with the same construction abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 da*g1forrpl ioy�q }velliirr//
6a.Well ID#: MW-1 abandonment to the following: 9 LU 4
Iflti:,
Division of Water Resources,Information ro _>lTt Ilft;I
6h.Total Nell depth: 55 (ft.) 1617 Mail Service Center,Raleigh,NC 276 73
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 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: 41.10 (rp Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NSA (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
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 40 00 abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016