Guilford_Well Abandonment_20241014 (2)

WELL ABANDONMENT RECORD � For Imenual us9 ONLY;
This form call be used fbr single or mid.ipte wells
1,Well Contractor In formation: )&F.LL ADANDONh1ENT DETA16$
Rich Lemire 7a.Min,iberofaclisbeliMahandoncid- 1
U1016anctorTame(arwt ll6%.wrNasofcllyalmntuninowou6-Hhisfl�rprapeny) pw retiitnpk live ae a� nuts-ntuerl a�rPW a,a, 'U,VLY wtaa fire sauna
axmrfrnctfaalulrarchnrrli�Rat irrncdmsu8ariffaau.�firrn,
2593A
7h.Approximate volume of rsater•rerttatining in wrII(%)FaN (guL)
T1C'We1lConiraAorCottifi�atloaiNnarbax
SAEDACCO FOR%rATERSUPPLYNYELKS ONLY.
Canipany Naa>rc lc.Type of disinfectant used:
2.',Pell Construction Permit#:,
Li4 pil rappthuble uvllperinAw(i.e.Cumt*',-Stete,4'dridkx•Lrrer&d{L eic:l Jumigti
7d.Amount of disinfectant usevl:
3.Well uke(chedi well use):
`dater.Supply Well: 7.1&Sealing matcri.;tLc,used ached:all ovit apply):
I7Agticnttitrat plvltinicipallptiNlic N Ncot Ccmcrit Grout to 13cmonitc Chips or Pellets
AGmthcrtn tl(HcatingJCooliaD Supply)' 011csidcntial%vatcr b7apply(wngtej. D Sanrlfientiytt Grout I7 Div City
❑Indti5tr6I/6mmcn:ial [3RcsidcntLal Watcr Sapply..(5Nkrcd), ❑Concieto Grout., 17 Drill Cuttings
❑itti lion• . 11 Spetiir VGrout El Gravel
Non-Water supple yell: C1,13entotute Slurry. CI Other(explain under 7g)
O1Notdtodlig: DRecovety
lajcction NYcll: 7f.For each tuaterial selected'a-boF•e-proslde amount of.titatcrials Wed;
t7AquiferitCclaai$6 l3Gt6uhd%61ciRemedialign Neat Cem.:471b ,Wtr:3gal. " Sand Cem.:lb ,Wtr:gal.
OAquifer.StoragetmORecoven, OSafinitvl3ani.cr gentoaiite. 31b ,Wtr gal.
OAgrtifeiTest ❑SlonwaterDrainaue
OEsperiutetual TcYhcto[ogvv. OSubsideuce Cotaltul 7g Prus4de a hriif do cdpNan df tlic'almaudanment prr►crdnn:
Meothenual(Ctoscd Loop) l7Tracer.
C10eathennat(Heatiny)Cooiin Mum) ®Otherim- lain'under 7 ) TREMIE.GROUT FROM BOTTOM TO .TOP.
d.Daic well(s).abaniloncd: 9-20-2024
&L Well tueaiton: J
ECI . . 1f:v.rr m: :: t�SC' $dnu y qua
Facilit)'ithincrNmrx Fanlity1DbCtrappliwbk) - ,y
,8:Certiltcaliaic
1239 Rock Creek Dairy Road Whitsett, NC 27377 � rn' 9/21/2024
1?14sical'Addres,City,muf Zip' Si�ytalntiota ;it>clWeflCoruia.aorarWcIIOlvwr Dttp
GUILFORD 8P siga:ing this f0riti;.l bemby rertlfy,that dw i vell(sl was(Beene}abtuidoned in
Cmuiiy P=el lilcmifieatln'o No.(PINj acxxnlciuce tvrth 15.4 X01C.02C:0100.ar k.0200 iGell:GarislrttGiurs Stonehinis
and did a copy oflldvrccurd has beenyrp vided(ofirswellattl)en
Sb;tititude and iongitude in dcgmec lntlatittas/sm.nds or decimal dcgmcs:
(Ificell ra ld,ow Ln 0,11a me siarutcall) 9.Site diagram or additional well details:
36. -79:053569 598642 You ttia}use the bank of this page to:prov�ide_additional tell site details or melt
N NY abandoimten t details..You tuay also attach athiilioual pages ifaaecessan
i
CONSTRIICPION DFTAITA OF WE'LL(S)DEINC.AB;INOONFD SURUVITAL INSTRUCTIONS,
:tllrtrtr.ta!r1J rori�•1tacLiun rictrnlfsJ If divilraril4. fcv arrulhylr rtr{eitidrr•w•rShn•icutir wppfp -
ireliv ONLY virhdwsvmerauavcDotciznrrtlorrscrit._rouourgrbmiiwre urirt 10a.Far All-,Wellc: Submit alas ftim rdthin 30 day!5of completion of wall
64.Well #.SVE-1
ID abandorimcnt to the fallowing: !
I,
Division of�YaterResourccs,InformationTroewing Unit,
Gb•Total mt'eti depth: 23 ((t,) 1617 Mail"ice Center,Raleigh,XC,2769971617
lob.ror Titicellon Wells: In additiou'.to sending the form to the address in IN
above.also submit one copy of this forni withiii 30 days of compiemioni of miell
6c.Borehole diameter.2 (in•) abi tidotuneut to the fouatitiing:
I
fid.Watcrletcl.bdon undsurfacc NONE (ft,) DivisiottofIYntcrRccources;Undeigrutudlnjc'ctionCunttvlPr+ugrant,
U 1636 Mail$cnicc Ccntcr,,Nalcigb,KC 2709-1636
i
Ge.Outer casing leu�tlo(if known): NA ( .) loc.Fnr\V iMr Stmnlc&-Hiaiectinn NVe18v: In addition to.se.nding the form to
the addresses)ab#e. also submit oit6'copy of this form}within 30 days of
completion of well abandonment to JhCr county health department of the county
Gf.Hnncrc:rsin;�mbing length(if[m where abandoned,own):NA (ft.) ,
6*Screen Irtmgth(if Mown)-N 00
Fatni GtF-30 North Canitlm Depanmcm efEnvimnnment mil Natuml Reso4mes-Dli isiou of WarcrRcsourn s Revised Aqua 20 t3
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