Guilford_Well Abandonment_20240423

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Smith and Jennings Inc (Adam Hill) 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
wells abandoned:
Adam Hill 37.5
7b.Approximate volume ofwater remaining in well(s): (gal.)
NC Well Contractor Certification Number
4061 A FOR WATER SUPPLY WELLS ONLY:
Company Name 7c Type of disinfectant used: Chlorine
2.Well Construction Permit#: 24-041-WAH R00247
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.)if known 7d.Amount of disinfectant Used: half pound
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural ❑Mumcipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ■Concrete Grout ❑ Drill Cuttings
Ohrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
7f.
Injection Well: For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1.5 CY
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experirnental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer dug out drilled well cut off below grade chlorinated
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
then poured concrete to surface and above
t Date well(s)abandoned. 4/8/2024 for cap <+--�.:t�.y ��
SA.Well location: APR 2 2024
Premier Stores Inc
Facifity/Owner Name Facility ID#(if applicable) S.Certification:
CYt'rC��3t�.i
4005 N Church St Greensboro NC 27455 .cQ� 4/10/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Guilford 7866693475
By signing this form, I hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15,4 NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.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:
N 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 WELDS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach wellconstruction record(s)(available.Formultiple injection ornon-water supply wells
ONLFwith the same construction abandonment you can submit one,/bnn.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 94ft (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Inieetion Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 61n (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 25ft (ff•) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e Outer casing length(if known): (}>t) 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): (fL) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

PROPERTY SERVICE CHART
ADDRESS REID #
SERVICE COMMENTS DATE REHS
Well Abandonment Permit issued. 4/8/24 KCM
Abandonment Adam Hill dug out a drilled well and cut it off below grade, 4/8/24
chlorinated it and poured concrete from a truck 94 to the MKB

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Address:4005 N Church DISCLAIMER:
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The data shown in this map is for
Permit #: 24-04-WAH R-00247 Feet public use. Guilford County makes
no warranty to its accuracy;all
Issuer's Initials: MKB data sets and maps are for
1 inch = 190 feet geographical representation
Date: 4/9/2024 only.

�J\,jpRD CpU�T` Environmental Health Division Water Quality Section
400 W Market St.
• ' su Greensboro, NC 27401
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April 09, 2024 Permit #: 24-04--WAHR-00247
Adam Hill
Ref: 4005 N CHURCH ST GREENSBORO, NC 27455
Dear Adam Hill,
This letter certifies that to the best of my knowledge, the abandonment of the well at the property as
referenced above, was abandoned according to the Guilford County Well Rules. The record of
construction has been received and the well contractor has certified that all work was done in
accordance with the aforementioned rules.
The well permitting, inspecting, and sampling programs and policies of the Guilford County
Department of Health and Human Services are designed to document that the aforementioned rules
are complied with in order to protect the public health and groundwater resources in Guilford County.
Such programs and policies do not guarantee potable water quality or adequatE! water quantity in any
well.
If you have any questions concerning well rules, the record submitted by your contractor, or how to
test or treat your water, please do not hesitate to contact us.
Sincerely,
Environmental Health Specialist
CC: Property File
400 W Market St#300,Greensboro,NC 27401 1 (336)641 -7613

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health, Water Quality Unit
400 W. Market St., Suite 300, Greensboro,NC 27401
Record of Construction, Repair, or Abandonment of a Well
Address of Well: 00 '�`r LATITUDE 3_
Well Permit Number: _ - "Ol-I� W -(Oo ZJ 4 LONGITUDE
Well Contractor Company: Completion Date: Z
Total Well Depth: ft. Well Yield: gpm Static Water Level: ft.
Outer Casing Material: Formation Log
Casing Diameter: in. Casing Depth: ft. Depth Description
From: ft. To: ft.
Inner Casing Material: From: ft. To: ft.
Casing Diameter: in. Casing Depth: ft. From: ft. To: ft.
From: ft. To: ft.
Grout From: ft. To: ft.
Depth Material Method From: ft. To: ft.
From: ft.To: ft. From: ft. To: ft.
From: ft. To: ft. From: ft. To: ft.
From: ft.To: ft. From: ft. To: ft.
Water Production Zones
Depth: ft. ft. ft. ft. ft. ft. ft.
Yield: gpm gpm gpm gpm gPm gpm gpm
Method of Repair:
Method of Abandonment:
Ca
I hereby certify that this well was constructed, repaired, or abandoned according to the Guilford County Well
Rules in effect on this date and that a copy of this record has been provided to the well owner.
r
Well Contractor: ' i/ Certification #: '_ J_�, Date:
l ���/ ��
Record of Pump Installation
Pump Installation Company: Completion Date:
Pump Depth: ft. Static Water Level: ft.
Pump Brand: Pump Size and Rating: hp gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on this date and that a copy of this record has been provided to the well owner.
Well Contractor: Certification #: Date:
well depth 94 ft static water level 25 ft
Revised:January 1,2009 half po nd chlorine

J�_FpRDCO(l Environmental Health Division Water Quality Section
400 W Market 5t.
o , fy� u) Greensboro, NC 27401
n IIh�1� [phone]
AI.TN� Permit i to Abandon a Well
y� '�
Address: 4005 N CHURCH ST Permit Number: 24-04-WAHR-00247
GREENSBORO, NC 27455
Comments/Specifications:
Existing drilled well to be properly abandoned by Certified Well Contractor according to Guilford County
Well Rules. Well contractor to schedule required inspections. Call at least two hours prior to
abandonment to schedule inspection.
Above Information Certified By: �i), /t0 Date:
Owner or Authorized Agent
Permit Issued: /4 W, Date Issued: 4/8/24
Environmental Health Specialist
Permits for the Abandonment of Wells shall be valid without expiration.
Page 1 of 2
400 W Market St#300,Greensboro,PIC 27401 1 (336)641 -7613

4/8/24,9:13 AM GIS Data Viewer
Guilford County, NC
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Parcel Number 139955 Total Out Building Value
PIN 7866693475 Total Land Value 2755700
Owner RAK PISGAH CHURCH LLC Total Deferred Value 0
Mail Address 7609 BUSINESS PARK DR Bldg Card
Mail City GREENSBORO Appraisal Model Code
Mail State NC Deed Data 6/6/2022
Mail Zip 27409 Neighborhood 7866CO3
Property Address 4005 N CHURCH ST Property Type COMM
Legal Description PISGAH CHURCH RD AND N CHURCH ST LO:4 PL:213-102 Structure Size
Deed 008623-01692 Lot Size 16.87
Plat 213-102 Year Built
Condo Bedrooms
Total Assessed 2755700 Bathrooms
Total Building Value 0 Grade
Disclaimer:While every effort is made to keep information provided over the internet accurate and Map Scale
up-to-date,Guilford County does not certify the authenticity or accuracy of such information.No
1 inch=333 feet
warranties,express or implied,are provided for the records and/or mapping data herein,or for their
use or interpretation by the User. 4/8/2024
hftps://gisdv.guilfordcountync.gov/guilford/ 1/1