Forsyth_Well Abandonment_

WELL ABANDONMENT RECORD Boaiftmd Use ONLY.
This fit can be+teed for singe ormtdGpe wells
1.Well Calsom or isfouatlow DETAGA
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...�.a.Md_�=l`lac( S Ta.Number of Wells being abandoned:
wail ConnaaaeName(Q—f mwdoamwpaca djye6aedonmg Won ortkislberptopMW) For b b#u►on or nm4Wer', ,sage Q wM de attar
eonarnxtlon/alimrAoeofenb ynrr ama,etaarr oms�rar. .
NCwanCam CaliBaat�axwa6es lb,APp�moavahoneofwater�dng inwefl(* ram)
' �- FOR WATER SUPPLY WZEMONLT
CompanyNente %Type ofdIdai&dant wed: �s�i Let Al
tiler 60gpp0aoete wettpenntp fit.CM*&M Youtmtae,twaslon,+tc,!VAMM Td.Atteonat of dWmft:etant teed: !�/
&Well tome(ehee>swell on);
Watff Sappy Widk 7e.Seaftnexterlsh used fdmekdl Watap*
DIPAMPUPdAt a NeatCemmatkout a saanitaChip orPdlets
ai l cxeatingl000li�supply) Waiar Snpp�►(side) o�Cott t3cout a Dry Clay
abt�atrndlComt�tdal 131teddential water Supply(skated) >Cf nmetCen to Gmut a>M'U Cuttings
alffilaft a Spwj*Groat a Gravel
NwwAterSttpp(ywd: 0 BeawniteSlurry o Ohs(espWn+order710
aM 79 For each mstwtal selated above,provide amenat o[seatsrbls wawh
DAqu&Rm*erga 00mundwaierRemedletion 3 Yd
Mquift BMW and Reaavery aseliuily Dazda ,
aAgt&Ted t:iStormwab�Dtaittage
CapffimentelTeelmolow 0suhsidencxtbntrol 70,PravWe a brief dmdptton of the abandonment Beseeches:
aaeotfwmal.(Closed Loop) aZYacer
00gorhaaml Rerun) 00dtet undue 7
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4.Date well(s)attandoned:
516 We0locallem:
l lil� !/ gao0ilYIDrt �)+ L Creation: M¢ufvf AD%A 1 J130G Utts9
Mpreiesl Ate.Cby.and zip sii�gtorrfl( ell t7oaaoerawoll gaaror cote
�,....._ ' By 8Wft dds jbm I hereby ca:*�dot the w@(q)wor Ossm)abanda d In
CMInliPaW hka ifinOw No.(PRO accon6rrce with ISANCAC 0IC.0I00 or ZC.O=Wag(3sndraatieer
and that copy of this record har bewipv tdedto I&well amnsr.
5b.i atttmk and hngfth In degeeeaimWntestsewnda or dedenol degrees:
(ifwA toed,owbNtatgissotliaisa) 9.61%dlW=orad Ode W well 44&W.
D, 2 G 2 7 you may use ltte lade of this pp to provide additional IND sIbe delab or well'l % N W abandonment details. You may also Wob art MW pan if nxessety.
AwdY we ww"can near W jrawffielkAr mobtAe tq/srxtav or w"aar?�4'
ml(etltl'LYtrtdidk�reaoaar4 AyomCOadMonefim 10t Far All Weft Submit this lbnn widcin 30 dep of boa of wall
6a.Well Mt.
abendonmvlto the Mw*;inF
Divivi n of Water Remmmies;khrrsetes PMMft Uedt,
U 1617 MfiServIwCea4er,RAW&NClT699-1617
6b.Totdweb depth: R)
10b.R- aGte"Walk In addition to sending dw form to the addmas in 10a
abovet �
) also submit anou this form widtkt 30 daps of aomplatimr of well
6e.!lam deter.
? ey Dh+bdon of Water Resoarca,Upda>poohad b oa CosMal Ftgpam,
6d.waierlevei below grow d uahce: ) 1936 man serviceCentw,Rabt^WC 2709-1636
6e.Onhr using bn�glb(lt?mowa}:,_ (g:) 10c.Per Water Sammy 8c hdogtion Waaa: in addition to S rho etm to
the addresses)above,also submit _ them within 30 dip of
completion of weu abandonment to a department of the county
69 howeradogliabbg h00(if knewO (M) wbom abandoned. •
AUG 0 9 2022
NO DEQ/DWR
FamOW-30 NonbckwinaDepermmofBmvhonam=dNakaa PAmtans-Divislonofwam"Central
Office
Rev)edAwa12Q13