Guilford_Well Abandonment_20240318 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
I.NN ell Contractor Information: WELL ABANDONMENT DETAILS
Brian James B e I I i s 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor\,me(or well owner personally abandoning well on his/her property) well construction/depth,only 1 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): ~1'5 (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: NSA
List all applicable well construction permits(i.e.t/IC,County,Sure,Yartance,etc.)iflmown
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 s Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
PlMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation ~80 lbs Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage ~20 Ibs Grout
❑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
a.Date well(s)abandoned: 3/8/2024 capped with grout to surface grade. Flush-mount
5a.Well location: protective manway was filled with grout to surface.
Chandler's Produce & Gas 00-0-0000009972
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: _
5436 North Church Street, Greensboro, NC 27405 �— 3/12/2024
Physical Address.City,and Zip Signature ofCertifi d W Contractor or Well Owner Date
Guilford 7868767393
By signing this form, /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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy ojthis record has been provided to the well owner.
(ifwell field one lat/long is sufficient) 9.Site diagram or additional well details:
36.1829210 N -79.7873170 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 WELLS)BEING ABANDONED w '
s i available. h'ormulti leinectionornon-water.su l wells SUBMITTAL INSTRUCTIONS
Anachwellconstructionrecord
()f P 1 supply MAN 1
ONLY with the same construction abandonment,you can submit one form. .?10s. For All Wells: Submit this form within 30 days of completion of we.?
P24
6a.Well ID#• MW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,``
61). rotal well depth: 50 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (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: 40.48 (fk) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A VL) 10c.For Water Supply&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
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 40 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016