Guilford_Well Abandonment_20240617 (4)

WELL ABANDONMENT RECORD For ImcriulUw(ML\-
This form.an be used for single of inulfipk%ells
1.Well Contractor Information: NMEYf DETAII ti
Scott Hunt, Jr 'A.umber of welh briny;abandoned: 1
w,!!l e i rt:au t h„tr•rot welt o..aer p.rsowtls ah%tolomag"eu on hx Mr ptopt:n)1 n+rth(+tr :r,1e'.:�..., ow."-x,ori r • p(A "M 0%1-1 Woh the U"'or
„..rrr<n•n th.w•hwm,dr ..•n u111.Nlvtof.Yt<hwoot
4561
NC Urlt t'r,ntracUrrCcndt inn^turi+cr 7b.Apprn\imate%olumr of Mates remaining,im inello# %gal.)
SAEDACCO FOR WATER SUPPLY%F:LI S ONLY:
' ` 7c.T%pe of disinfectant owed:
2.\\toll C.tn.Iruciiltn Pcrmit a;,
13J YCii Ji/m+:..+..a'.+. Wnrt..%G11e.l arsawl•.1Mavhm est.,Itkotirmot
"d. \mount of ditinfccunt s,rd:
3.N ell oar(cbc&-w ell etc):
%%Ater Sappl} well: -�.NeAlin-,materials.will(eberk all that apply):
CIAI mnhurol ❑1bbMlCtpal'Athl0. X ":1:(,nl.nt(irotN Cl Hcolonuc Chip&ot Pcllctc
D(icothemwl(Ilcming'Coobtnr SupPl\) DRccdcnul\Paler Supph isur.•1.1 ❑ Sand(-torten(,rout ❑ Dirt CU%
01ndusimil:Commenral ❑Raadottltal AAter Supph #%hamd ❑Concrete Grout ❑ Unll Culnttgs
Dtm wu D Spce-wk� Grunt ❑ Gra%el
Non-N a(rr SnppN W ep: I I fklronrte Slum I.l O(het(explain utdef'•g)
ODhlurnlomte DReru%rn
Injection 'efl' "f.For eaeb material wktted ah00%e.pr otide Amount of mmirrisk ntled:
❑Aqutfrt Redraw ❑(iron d%tatef Rewdt awn Neat Ctn(m.:941b ,Wtr:5ga1. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Stor"c and Reiman Dsdluutt, tl:rrner --
DAqudet•1•est USlonnwatct Ur•Auwgc - ---- --- ------ -
DEVmmerual Terluwlog► Dsubstdence Cowto) ' Protoide A brief daxription of file AbAndonmcnt procedure
DCANxbemul(CIowd loop) UTrxef
trittaty grouted well from bottom to top; removed cover and
OC"thermal(He tintrfoolingReturni f 1011rerIC% uttdef'gI f R t
% r...
cut pvc below surface It``!L„,
kDattwtMOsbandoned: 5-16-24 JUN 1 7 2024
Sm.\Fell location:
High Point C&D Landfill
racilm Y►n..t ,. rR tn.tnr(/fapptt.abkl •Cenificali(on:
r
5830 Riverdale Dr., Jamestown, NC 27282 +�� h 5/17/2024 —�
Ph%seal Address.CK%.and Zip /<<:+!- r:r.4 Well(OfAM Mr fir WCU O WWr Mole
Guilford Ifs•mpitow Nits fiwal, I AwAi.cYrt7Jt them delta artless it to/tour.aNtaadaowd in
('tMaat PAtcd IdetalfwA lud No 4PI%1 at c4pnbtlk•r%into 111 AI,1('01".d100 or V 0.VJ7 Well L onwnwclltoa SAp"A.tt
acid thx a c.,p of this mtord hers Mtn 11rrnwk-d to the M'ell Ottorrtr.
Sh.Latitude And longitude in degrees minutea'vnwds or decimal deRreec
t11 aJ;(WW :�v Ed k.p t..nff'XIS: 11.Site diagram or Additional weff detafl4:
`1 Oil nl:ns use tilt b:wi, of this page to Prot Otte addrtkan:rl%tell SAC tk-131 s or cell
N __ N tbatldonnier(de(atta 1 ou nu% aho Attach aMuk)tral papas if netiessan
(()\,I RI t 110% I1t`I it11 *,OF WELI.(S)RI'IV; \B 1110"F1) SUBMITTAL INSTRUCTIONS
r t ,uhuk>w .w,Inoo..wuf/itA+raecnr /wlW:WYr/r.Yi<'4,IA l9a. For AU Wrllc Stnbm(t fhn fomt etithnn .10 dms of campktron of well
ow.\1 ell I I1< P2-1 :Ibatrdonntcm to the foUowtng
Dititinn of Nater 11"ouree+.Information Processing I nit.
51
161'Hail Service('enter,Rslrigb,NC 27WIP-1617
olo. I otdl MrII Ih•111I1: Ih.)
10b. For Iskrtli n Wi t,: In additiotr to sending the form to the address in 10a
abu%e. a6c subnut onlc ctvt of thts tone within It?dins of corrgliction of well
lot.Rtlnludr dianaler:2 —_—.— _tin► *3ntdunnwrii it)file lollowme
od.N Ater kttl hrlow L►%food wliarr: 15 (�) Dlti%inn ttf\Ai Ater Rt•Mwrtea.f nderground Injection Control Pnturam.
16.k,glad Senile Center.Rmkigb.'tS,tC 276►N-In3t.
Ilk. For Natcr Su ols do lnkrfiun WeRs: In addinion1 to K•ndnlg the form to
oc.fluter raing It n;ah tit k um n 1: Ifs.►
Ilk' atklressotso ;IbotC. alw st$Innl ottc taliq of this fume %ullnn to tL•n%s of
conipk(kIn of well ab:urdtini n`nu to the courm hcallh ticatnnrettt of the:oasts%
w h;te:thlttdm><A
of.Inncr tAsinr tuhin-ten-•th tit kii.."n r. (R.1
to:!.1,4:nt•n length(of Ltimsni: (R.)
t , I A- Noah C'arutnra Deparun;ts of Eo%i/unnald MA Neural fttwmes Do mkoti of Na(cr!humans f(:.ecd August-111 l