Guilford_Well Abandonment_20240529

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor information: N'ELL ABANDONMENT DETAILS
, a2y J j X/ w o l 7a.For Geoprebe/DPT or Closed-I.oup Geothermal Wells having the same
Wnll Contractor Name(or well owner personally abandoning well on hk1her pruperty) well construction/depth,only I UW-30 is needed. Indicate DOTAL NUMBER of
wells abandoned:
NC NVdl ontrtctnr C nificaAR
7b.Approximate volume ore ater remaining In well(s): (gal.)
r� FOR N'ATER SUPPI,I'WF.I.I.S ONI.Y:
Company Nana l
7c.Type of disinfectant used:
2.Well Construction Permit#:
Liv all applicable well r mstructionik•rnrirs(i.e.U1C.County.S(ate. Var•ianre,clr.)ifknae•rr
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check aft that apply):
❑Agricultural unicipal Public ❑Neat Cement Grout ❑Bentonite Chips or rvrH�" r/ :� 2024
C
❑Geothermal(Heating.Cooling Supply) esidential Water Supply(single) ❑Sgad Cement Grout ❑Dry-Clay
❑Industrial/Commcrcial ❑Residcittial Water Supply(shared) ;Crntcrcte Grout ❑Drill C uttin jo,`v
❑Irri tion ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑(Rher(explain under 7g)
❑Monitoring LRecovery
Injection Well: 7E For each material selected above,provide amount of materials used:
OAquifer Recharge ❑Groundwater Remediation 2 - 2/
UAquifer Storage and Recovery LSalinity Barrier
f IAquil'er Test 17&orrmvatcr Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑(kothermal(Closed Loop) ❑Tracer
OG eothetmul(Ileatin ,Cooling Return) ❑Other(explain under 7
Z,.Z y /r rU
4.Date well(s)abandoned:
5a.Well locatio
l-j!
Facility Owner Name Fac''ty ICt#(il'applicable) S.Certi6caHon
Physical AJdrecs. 'iry.and Zip Si - . i!Caaa�ctor or Well Ov ter at
(/(/` 83 signing this form. I herehr eer7ifi•that the welNs) was(t+ere)abandonned in
County Parcel Identification No.(PIN) acenr&wre with 15.4 A'G1C 02C.Of00 or 2C.0200 lVel/Construction Standards
m oh•this recort/has been provided to the ivelf owner.
Latitude and longitude in degrees minutes/sccunds or decimal degrees: and that a cal
(Kwell Field,one tat long is,sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
+�N / W abandonment details. You may also attach additional pages il'necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
.ladehnellcuastnrc•tionr,rurJtstr •oiluMe. hbrnralriplcinjrctivaornun-warrr,applru,•!h
O.NLY with the same crmstr art r'bhandonmeru,You can submit one Conn.
10a. For All Wells: Submit this firm within 30 days of completion of well
6a.Well 1D#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (R.) 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 (In.) above, also submit one copy of dtis Conn 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
6e.Outer casing length(if known): (R•) 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 vfiere
6f.Inner casing/tab(ng length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form CiW-30 North Carolina Depannieal of 17n%imnmental Quality-Division of Water Resources Revised 2-22-201 n