Guilford_Well Abandonment_20240318 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WEL1.:1BANDONMENT 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): _1.5 (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:_
2.Well Construction Permit#: NIA
List all applicable well construction permits(i.e.111C,County,State,Variance,etc.)tjbtown
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 N Neat Cement Grout 111 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 Slum ❑ Other(explain under 7g)
RMonitoring El Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation --80 Ibs Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage '20 IbS Grout
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite was placed in one foot lifts and hydrated
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
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/(Tuner Name Facility ID#(ifapplicable) S.Certification:
5436 North Church Street, Greensboro, NC 27405 3/12/2024
Physical Address,City,and Zip Signature ofCerti ed II Contractor or Well Owner Date
Guilford 7868767393
By signing this form. 1 hereby certify that the we//(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0/00 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy ojthis record has been provided to the well owner.
(if well field,one tat/long is sufficient) 9.Site diagram or additional well details:
36.182864° N -79.787329° 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)ijaradable. 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 o�,completion of well
MW-3 abandonment to the following: < ( ?.� ;1
6a.Well ID#: �
0 ~t1 �
Division of Water Resources,Information P !Q n U it,
6b.Total N ell depth: 45 (ft) 1617 Mail Service Center,Ralei C 27699-1 7� ?024
10b.For Infection Wells: In addition to sending the�fotF Air ess in 10a
2 above,also submit one copy of this form within 30 days " pf siftL.
6c.Borehole diameter: (�11.) abandonment to the following:
6d.Water level below ground surface: 39.90 (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 Supply&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
6E Inner casing/tubing length(if known): 35 (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