Guilford_Well Abandonment_20240617

NVELL ABANDONMENT RECORD Fog lairfaal Use OWLI•
1 hi,t,,rm ati be ustd for smtgk o►mtdlipk wells
I.W01(ontrAcnlr Infi,i7namiou: WELL.ABANDOiVMENT DETAI)ti
Scott Hunt, Jr 7a Vuitwiberetwetibtehfxsbsnibwed: 1
N,11 Cmdl:wcwl NArlt tot tali oi,mi pm,4-mtlh ARlt4toung%o:J orr hms her ptapem i t..r n+wioo4 :n t't tau( .r fo..,_r.H<r ;wrrtt We)(t MLY With 11w• M&W
.' a,srw((l.N!ut•V&ho#pw'nr,t...t�9,.MtV fo(.Nie hours
4561
7b.Appmaimatr imluntr•of watrr remaining:m well(s19
•.l A.1 l�!'.I'.!�'�.f l.rl a:'..a1Nxn Nm,r'tKr
FOR WA'LF.RSI PPI l NELI%ONIA:
SAEDACCO
(oni(uln NA"Ic T
.c.T)pr of disinfectant usrd:
2.W'dlConstrutte.n Permit p:
I,Jullayttc.thk Web;arna:.,,a x ' .x tla,�t+Mt.idndq(P hue toms- , ,f►la,rq
7d Atwwwl of disinlcatAnt rK•d:
3.W'dl ute(check in ail use1:
Water Guplth dell: 7r.Seatiwf materialio and ichecl.all tlut Apply):
DAgmaltural ❑%hmktptl.Puhlt< a Nu31 Cement Gnxit I I Ben tonne Chips Of Pellets
DGoothmul(Hering('oohFw Supply I ❑RcsidcmNial Water Supph isinglc) D Sand CenicM(trout ❑ Dn Cb%
❑lidusinal;Commmial Dl(csrdcislal Water Snpph istlared) ❑Concrete Gnome ❑ Drill C'utt tip
71rn tiou ❑ Specials• Grout ❑Grai cl
\nit-Water Swpph WrR: 1.1 Penonite 51unN ❑Othet(e\plam under"v;)
MMuntionne DRcco.en
Inirctltrn ill: 71.For each iawri it v(ct red Atom e.pr•otidr antoant of inAtrriAk used:
0AgoifcrRcalurec ❑(irtintidtialcrRcntaliation Beat C4m.:941b ,Wtr:5gal. Sand Cem. :lb ,Wtr:gal.
❑Aquifer Storage aid Rccos to MAnuti Winer
❑Afluiler Icst DSlonuuatetDraarsgc -- —
❑Ezpennmrrual 1ctltnulvpi DSibsmdewee Control Prmi ide a brief dasciiptutn of the shandonmrat procedure:
LiGeofhcrntal ICbscd I otipi CiTwet
pulled well out of ground; over-drilled out all well
06mliemtal Mewing Ctxilins Retumt 00dWr(CXPWn Uftkr'?-R I --
material and grouted hole from bottom to top with tremie
4.Date%CHI%)shsn&.ncd: 5-16-24
Sa.Well h►cAtit.n: `LJ L"
High Point C&D Landfill JUN 1 7 2024
. (h.,xr'+%.... � ,„ tfir rif;tpplu.it+ki A•CettYkatdatr:
5830 Riverdale Dr. , Jamestown, NC 27282 f.f ,�'-.a,-'f �rx;"ei170,Tr_!b�_'SM/2024 _
a!:4-!;kd Wits(011mim nr Well(haver Dale
Guilford Bi stXafng Nits ptrot. I heath►i erhA Amur tar wrllr.e, it etc rwm(d&mk*Wd M
(wiuy i "..:IdetrdaWY,nNotPlNl uae�tnkmerrtdrl�.11(:1( 9:('.fll(N1ur:( ().r111(ir;'11C0"'_Jrueprn,.t7aneknlc
wtil that a c.,ri tot this re(ord lsav he or pnrnukd io the v e//owner.
ib.Latitude And longitude in akgrerstminutev-Avo ids or decimal deErm:
Iit«ct,Laid .,ra IA Ii,w-,a...il!.,.'tt: 4.Site diagram or additional well details:
You no% use the back of this page it)pre nk addrnonal well sac d tads of bell
W :it+airtk•mtireM details You ma% abut attach wMitiunal papm if tttN rssan
CONSTRI( 110% DFl It It OF N i I I lsi lillN<: it"itNo DON F1) SUBMITT Al.INSTRUCTIONS
«uh Mt.Wept.tag.+u,Ku•m r•,r.,t•.r».-.ar ,.a....a.w• ;..,.<r•.» loa. For .'►11 W Wits: Submit ihm form within 10 dais of compaction of hell
r•A.N ell I ltn
PZ-3 *m donnicni to the following
Ditition of NAter It"itarcm,Information Prmcrssing knit.
20
lit I' NIAiI%en ice Crnter,RAleigh.W 2 7 699-161 7
nD, Inla1 ttt•II dt•pth: Ift.l
lob. Fur inigc6ion We Is: lit addition to sending the form to the Wdiess in Wa
abow. also submit Otte cop% of tips form within 1)dins of cortiplrt"of well
r,c.Rorchoh dianit ter:2 law.) ahandonnteM to the folkiwmi;
Dia►,ion of Water R"wrccs,I.adertruiind Injection(oniml Program.
(tit.N titer keel below tiytuud wrist r: 10 lfLl 1636\tail Scnicr Center,Raleigh.M'276"-1636
life.for Water Submit & Iwkr(iYn MAW In addition to saymdmg the form 10
Oc.(tact o.Amn;_-Icn,th iit Enna nr iR.► the addressocto aboic. also submit otw cup+ of this fomp wifhin 111 da%s of
completion of well abmionmozra to the couwh health department of the cousin
w hctc ah m(kniccl
,.t. it,:
tag.Scrrcm It•n:;th,it Lnni.n l: A)
Fong Gar•ti Nontt t'solma D.:pittim;nt of Eut iruiuuwtd and NawrAl R%%owccs No i„to of%:art Rewittkvt Itc,teed August 9.1 t