Forsyth_Well Abandonment_20220725

a RECEIVED
JUL 2 5, 2022
WELL Le AJIDt MONME1W 1t p CORD For latenml Use ONLY: DW011100
This form can be used far single or multiple lvclls
1.Well Contractor Informadon: `i'ELL ABANDON)iy NT DETAILS
7a.Number of,,lls being abandoned:
Weil Contractor Nume(orwdloancrpcisonallyabandoningwenanhidherpropert) Aor muMple injection or nan-frorer sappy, irells ONLY with the sane
consrrttctran bbandunment.ymr are submit oneform.
J1Ff F
NC WcU Contractor Ccrtification Number 7b.Approximate volume of water remaining in well(s): ✓ (gal-)
Aqua MI, Inc. FOR WATER SUPPLY MMLL-S7ON©©LY.
Company Name 2 G ? 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all appDeablenrtl permits(Ga.Cmui(It State,Farimre.hyecNan.etc)ifkumrr 7d.Amount of disinfectant used: .
3.Well use(check well ase):
Water Supply Well: 7e.Searing materials used(cheep all that apple):
O Neat Cement Grout ❑Bentonite Chips or Pellets
QAgicultural �Ivi�icipaUPublic P
OGeotltennal(Heatine/Caoling Supply) �Res►dentid Water Supply(single) 0 Sand Cement Grout O Dm Clay
DindustriaUComrnercial OResidential Water Supply(shared) EI'Concrete Grout ❑Drill Cuttings
ClIrrigation ❑Specialty Grout 0 Gravel
Non-Water Supply Well: O Bentonite Slurry 0 Other(explain under 7g)
OManitoring ORecovery
Igjecdou Well: 7E For each rauterial selected above,provide amount of materials used:
DAquiferRecharge OGround«alerRemediation
Mquifer Storage and Recovery OSalinilyBarrier
OAquifer Test OStantmater Drailtaee
OExperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
130eothermal(Closed Loop) OTmcer
OGeothennal(licatinglCoolingReturn) OOther(explain under7g)
l/GC S ZD 3p'",49-a/11; !al fi���f✓etiClLf-C / �'�G�4
4.Date well()abandoned:s � — p
C%S�ry T r�G" IJ O.yG.t'C-- pG4;•� G`UG -
Sn.Wall location:
Facility/Owner Name Facility i 4(ifopplicable) a.Certification:
Sri 1'.S•PC-� f/ty pt ► GcJl d6%o����>zi �?t03_ALM
Physical Address,City,and Tap SipYtnre orc4tificd well Contra for or Wail Owner Date
By signing Oys form I hereby terrify that the wells}was(were)abandoned in
County Pared Identification No.(PIN) accordance with 15A A101C 02C 0100 or 2C.020D Rrell Construction Standards
and that a cape of this retard has been provided to the well airner.
5b.Latitude and longitude in degroodminuttstseconds or decimal degrees:
(ifwall Geld,one lat/tongis sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCCION DETAILS OF WEUM BEING ABANDONED SUBl ITIAL flNSd'Rl(lC1TONS
Attach well consnudion recOrd(r)if mvrifable. Far multiple 110CH011 or art-1rater supply
,rdb ONLY irith die some emirtruction-i7bundonmew,you can submit aimform. 10a. For All VVel2 Submit this farm within 30 days of completion of 6v.-J1
60.Avail Mg.. abandonment to Ore following:
Division of Water lgebourccs,Information Processing Unit,
6h.Total well depth: 67 (ft.) 1617 Mail Service Center,Raleigh,NC 77699-1617
10ti For iniecdon lhteris in addition to sending the form to the address in l0a
22,
Z/ above,also submit one copy of this fort within 30 days of completion of well
6c.Borehole dfataeter. / (in) abandonment to the following:
6d Water level below ground surface: (R) Division of OWater Resources,Underground Injecdon Control Program,
16361dM Service Center,Raleigh,NC 27699-I636
10c.For Water Sunniv 6c Infection 4i%eRs- In addition to sending the Fkam to
de.Outer casing length(if Imown):. (fW the address(es) above,also submit one copy of this farm within 30 days of
completion of well abandonmeni to the county health department of the county
mficre abandoned.
6E Inner casmg/tabing length(if Immvii): (tt)

s� FORSYTH COUNTY HEALTH DEPARTMENT tO_-, ,r4'- ' i`'
W¢ �� Division of Environmental Health
w P.O. Box 686, Winston-Salem, NC 27102
336-703-3225
z
File Number ,
Lot I 3r Block `R C?
WELL ABANDONMENT RECORD
Contractor C t;u a "f Gk i-'r'- Registration No. "
� F
Well Location:(Show a sketch of the site at the right on this form)
Owner
Site Address SITE DIAGRAM
Topography: draw,Cslope ,hilltop, valley, flat
Use of Well s Date
Total Depth x 4. Diameter -441, �
Casing Removed:
Feet Diameter
Sealing Material:
Neat Cement Sand Cement
bags cement bags cement
gals water yds sand
gals water
Other:
Type material "N),
Amount `� s
Explain method of emplacement of material:
t x F
e34 - -tf}�� ��SiHt �C �i^il, ; C3'kLAILlt1ca e" 3
1 tjS'- S �iF , 2 9 j, R
'Y ' tk`SAI ]t"a3 S.�� �.*CLI ore j€�.� �C..
I
G
I do hereby certify that this well abandonment record is I f
true and exact. f
Signature—ContraEto0owner I JDatQ
Sig at r6glE.H.S. Date cf !
PC.a17;_tit bP l
COPIES:WHITE—HEALTH DEPT. / YELLOW—CONTRACTOR / PINK—HOMEOWNER Rev&Reset FCPS 1-22-2014