Guilford_Well Abandonment_20240617 (3)

WELL ABANDONMENT RECORD L.
..l,unw!UseONLY
This formn li
,at uxd for single of multiple%sells
1.Well C'ontrarpir Infionnation: %%F'IT let ANDO1iMENT DCTAIIS
Scott Hunt, Jr 7a Number❑f%%ells being abandoned: 1
wol l•,,tstact i h.utc fist well oNixi per.-till,"Wotuug%c:J oii ha lwi ptcv.:m t F'w i •� r.-trrrrr uj(Ji , 1k 0M.1 write A' UA%e
4561
7b.Apprutimate solumv of water remaining in rcll(%1O (gal.)
NC%Yell C'ntar onr(i diftcnlinq NNtttrcr
BARDACCD FOR W 4TER SUFPI.l•W'ELI 4 ONI.I:
C'orrtpum N attic 7C.T'k pr of disiskttaat used:
2.Wdl Cetsuructxni Permit 9:,
l r.r<,11:4rf,Lt abi. ura •:r , t.,zr%.%&Ne.I aruivir larrarxwr,eh.,if Amo,sr 7d.Amount of dWofectant sled:
J.Well OK(Cbm-k Nell u%cl:
W Ater Swpph Well: 7e.Sealing material%toted(check all that appl%):
I-Agmuftur.,l ❑Mimicgsal Aihlw 111 Nc11 Cenictit Own t-I lkenionite Chips or Pellets
QCxofhcMLIl(Heath g'(boh1w S•WPb 1 011mdennal Walcr Saupph isinglel ❑ Saud CCnXM Gruut ❑ Dn C'ln
01ndus4mil Coninwicral ❑Raiideraial Water Supph tsharod) ❑CCovwfm Ciro% ❑ DWI Cutnnp
Olfrizaton ❑ Spaaaht Ciroun ❑Gra%tl
Non-W ater Supph Well: I'J Ileftolltle Slum U Otlitf(eiiplain undef'g)
®htutalonne ❑RCzo%cn
njrction Well. 71.For each material vk•cfrd aMr',e.prrr%itk Anit.wnt ref material.nwil:
❑AyutlrtRcchargc ❑Ci2RitdgJiefRcnicdoation Beat Cem. :941b ,Wtr:5gal. Sand Cem. :lb ,Wtr:gal.
❑Aipnfef Storage aid Rccm to ❑Salnun B.,trtet
0.44µukr'I'es1 ❑StornmalerDranlagc ----- -- ----..___�
❑Expenniental Ie hnolop ❑Subsidctict Conttttl 7g,Prin itk A brief dcscripttun tit the Abandunincnt pn%CCYlure:
UGeotl►erntal(Closed I dope liTracer
triamy grouted well from bottom to top; removed cover and
IlGeotheritial 4 Hewing,,CoofiP4 Remml Oc4buftexplain utldef 7 f
cut Pvc below surface
1.Date aetlb)afrandnnrd:
5-16-24 `• -'v L-i
�A.%%c11 h a Atiton:
High Point C&D Landfill ►Wisflp 4ra'!?efx,AawT LW
r.ttilm ri,,,><,V.itic � et iifapplu:Abrer
II.Ccrtifksdnr: VI
5830 Riverdale Dr., Jamestown, NC 27282 '+ �' f`t" 5/17/2024
Phs skal.Addrew Cn,.end Zip "r.M d!c. :r,d W C 9 Ca ain near wr4 cM tier DW
Guilford fat•opunst flies Itarwt. 1 herir4 i erh/v tAw My %riles. wait rwerey rsNwaWfi d in
CowW% Pmelklcirtf"11"No4PI%I Iw4wrthink-raith A(,1Cq?I'.t0100er:C... 0:1MR'vllConstrue1kin, mAw4v
ttwd thtw o crypt o1 this mead hav hear prr nvA-d to the w ell ou nar.
Sb,lAritutle and langitutle in tkVredmimstcWwc@Ml or decimal degtrcl:
lt/wcl:la W tw !i I ,-,.+alit_,,ta; 9.Site diagram or additional well detalls:
You nra% tat the back of this page to profile additional Nell sat de inh or sell
- -_- -- N W' abaldounicta detaib You nrA% also mt:i Ii aiWuional pages it rs ctssan
CON*�TRI l 110-, M I AILS OF W'EIJASI BEING AHANDQN F SUBMITTAL INSTRUCTIONS
mueop4r rmat(j,w.r rxKr wsUrr .,.;7•�r
.. f I r,rx irk .xf..titr r.we Hrr%t lox. For .411 Wells: Subunit flit% fomi aulun 30 dais of completion of Wdl
ru.N ell 11)=:PZ-5D handenmCrn to the follownkC
Dist%iira of W Ater Rrw.urer%.Information Pntce%%ing Unit.
bb. lutAl nclt depth: 41
161'MA11 Scnice(enter.Raleigh.M'27699-1611
(ft.l
10b. Fur Iniect(on Ndls; In add"t to sending the form to UK addtess in Wa
ahw%c. also sutinm rftr cM of this fort arthin In tins of cCnttpktioo of sell
be.%in•hale diAnieler:2 Iln.l
---- abaidoniitrnl to tilt Iollowuis:
Di%o.bn of%%ater Ila.,turee%,t ntkrgnaund Injection(oninrl Pntt;ram.
bd.W Ater kwel hehtw Lgviand%uirfare: 15 (D) I636%fail Sa•nitr(enter.Raleigh.NC 27WM-l",
lac.Foy W aicr.}goal% A Initrrinn!Fell%: In addition to seating the form to
6C.UutcrCA%in;,;lcn-_nh itl kin%%nt: (R•1 tfic addre%yc i abut. alit wbnai oiw .-i,p% of this farm within III ias of
compk-tiun of%veil ab.indonni;nt t.• ffie .antni% ticafth dcpannicia of the counts
%%h;te.,h..nrloik�tt
of•Inner taNin-_,rohin Icn.Rh tit Lnn%n): Ift.l
t,g,Iiivvn Icn;ph of Li m%%ni:
form GW-lit Nutt Catutim Mp nit►n!of Ein irutwictd aid Natutsl(icagtttct% Dit awtn of WAct kewitt ta% ki xd Au#ust 24it 4