Guilford_Well Abandonment_20240624

WELL ABANDONMENT RECORD C/\` ForlturtuilI-vONIY
Thi.Ginn,an he used for single of multiple wells CA
t_Well f(urtr'actnr Infin'nutinn: R'£LL ABANbONMENT 01;TAl[S
Brian Ewing 7a.Number of Adis being abandoned: 1
Welt Counactor Name for Kell uwtto petsottally;ibardomng wetl on halter ptopen)) Fv- mulapir enjeaxwr ur nnx-„urer sYmv( wells ONT I, -rrh the .a u•
.arrrr,,met ahtatNt'wvner,r.JVJN(YP%%uhhoi`ome filrM
4240-B
-11 111p11-\1111.4IvNIdutncrIf'A MCI'remainingin'111 : (gel
Nt 1kc11(utartdntCtnificalinnNnrtt4tct
F(►r.�1 �I11(�I 1'I'I 1 11 fLLS4►'�LY:
SAEDACCO
Contptm)Name %. I Ito of drnrlrfeYl.utt
2.Wdl Construction Pti-mit 0:
Lv; r•,;rlr:, ,; mari..N'iwe,i'ArldacY.hjW*om eh-.I Jwwitin -d.Amovot of disinfectanl used:
3.Well use(check w ell oset:
Witter Supph Will: 7t.Sealing materials all(cluck all that apph):
DAipwiihonrl ❑MtmicipaliPublic W Nett Cement Grout I I Acrtfonhc Chips or Pcllets
C343"thcnntl tficanni!Cvohng%An*N l ❑Residertial Water Supph I single 1 ❑ Said Centim Grout ❑ Dn CU\
01 dusm.d(ornntcrctal ❑Rcsiderural Water Supph isharod) ❑ Concrete Grout ❑ Dnll Cuttings
❑ twit ❑ Specialty Quill ❑ Gmel
illw►Water Supph Mell: f 1 Bervontte Slum 1.1 Other(c\plam under 7,g)
Mklotnfonn.L ❑Recu%cn
Injection Wrll: 7f.Foreach inatrrial s 4c"i d Alinit•,prvosidc amount of owteriab used:
❑Aqu her Recharge 06rou daafer Rcuictiixun' Neat Cem. :941b ,Wtr:7gaJ.. Sand Cem. :lb ,Wtr:gal.
❑ tlutfer Storage and Recm'en ❑Sahruty Bamer
❑Aquifer Test ❑Slornril Dmtturge - _- -- -
❑Expertmenurl Technology ❑Snbsttletce C'unatul F'ni%idea brief descriptirtn of the abandtonmen arm t prlrre:
❑Geothemml 4Closed Loops UTracer
Pulled temporary wells and tremie grouted borehole from the
❑Geothemnl 41-11eatin oolin Retuml UOtherl ain under 7g f
bottom up.
4.Date%Hit%t abandrined:
5a.Well location:
Patches Body ShopDIl
1,iilhlr ihutit Var. T'X.IIp)IDMU(;tp�I.aFlc)
1903 E. Green Drive High Point, NC 27260 -- Brian Ewing 6/5/2024
1'1 , sle"1.1, I I .:-ni, -� ,, 1 u.�A, ,J{h%wr DOW
Guilford Hy.rjgpuljg this fi)nn, 1 hereby certify that the well(s) was/were,aAwhAin•A to
u,n Pancl blind"tlrtu No (PIN) acx-ankmc with I3.1.'vCAC 011C,0/00 or X 02W Weil Cvnshwailon SAwicltll
and that a clop,of drts record has beery provided to the well owner.
Sib.I.Adtude and hongiturk•in(Iii-mrcminutes;sccondsordedowaldegrem
ttl,well f061.ow Lit You.t...altu:retvi 9.Site diagram or additional well 41etaNr:
hat ma% the file back of this pagc to provide adthoottal sell site details or well
N W abatdumncru details. you ma% also:Mach a 1,101tal pages if necessan
S'ONSTRII(-PION DETAILS OF W£LL(SI BEING ABANDONED S) 1011 1 1 tl IVSTRUCT[ONS
.tamp veil wnv"tism rrer,r.l-s:a u,whtl,:e. F.v mnJrtplr nyrcnrm ev w�rr•wvlrr salqir
»Yfdr ONLY vnh the aaratrc,ur.rtvr(wn ruhmrrrxre,hrnr. lua. Im All 11d1a: Submit this fotnt within ,0 days of completion of wYll
ahaudr.unlcot In the follouln!
6a.Well lDre:T�"i-1
Division of Water Rr_rrinrcm,Information Processing Unit.
Total sods depth: 13
1617 Mail Service Cuter,Raleigh.NC 27699-1617
61r. (11.►
lab.For[deer lan Wells: In addition to sending the fonn to the addtrss m loa
abu%c. also subrnlit one copy of this fomt widrin 30 days of completion of well
6r.Ilrrshii diamcfer:1 sin,► Avindonnkru to the folio%%ing
Disision of Water Resuurcm.C ndergrouad In jettion Control Program.
fid.Water Ill el beinw );wound surface: (ft.) 1636 Mail Srr%ier('enter,Raleigh.NC 27699-1636
111c.For Water Sumris & Inicctio n Wells: In addiaun to xrdtng the form to
fc.(httercaunglcn>th cif larownl: 3 (ft) the address(es1 abuue. also subnuf one cup% of this foml ruifhm ifs "s of
completion of wcll abardonnxiii to the :oiuiiN Ircaltll depanntcn of the coon"
a lrcrc aMndoncd
61'.Inner casin-_,iuttin,Icn_ah of I nnw n l: (f>t.l
6z.Screen length of Lilimi it 1:10 Al
Form Gil North Catoltru Ucpunutetr of Em wonnicnr aid Natural Resoraccs-Di%tston of!Pater Resotti Rcs Ncd Augost 21-1