Forsyth_Well Abandonment_20221128

WE1;L A'-�SANDONNIENT RECORD-' rcir:liitrfnatUse;oNil:
Tins form ca[I We uud for;stn (eloi'mult{ptvi�ells
i «dl L onh Icmr Tnfgrntafton. `, lYt AMNDOh4TF.N'r nt r tr
� 1
Brian Ewing cing al►anll nc�t 1
51'�l(Gni r�ctot 2,am�torsxetl oaur udl} il�tilnnin i3Jt off IPtct praltcrsj)� a' .. , x,c?Is Q��'l.T wrrli �rl. xii
. '. crt rr�sYnrtfrc�r chatlrmnt,�ttY;tr�n ea�r,rrrviift rAr�Jr,r-in.
4240-B
Apithai
NC tt�cll6omraaa�CvtilfkiloaTrntitb4T: b. ptr►xii','I inedf3rater_73I11ip2inV1;ll(K}:.• (fi t.)
SAEDACCO Inc
FpR 1)',ATFR-hS[SPPI;Y:R'F..I.X�S`Ohi y;
t'ang5:ur+Nsni
7, I ape of 111,gitf ditiit owd:
2 R`�Il Constrti�itmlYcrnut# �
3atYurrri/f,�l A±OY,;irYltjanKttilee�fvtiJx 1t,Vd):artruv,c•,�liyrci,nrt-t:(rt�� (t�rr
• , . . �tt,it►nuuntuf_di�rdP��ctintu�lti1'
Wat&Sappl.v Wc11.; 7c Scalln;nl(tc�I tis tt d Cchcs�._atl tb,tt aj plt)
'b 4gn�tttlttral - i�hhlnicip,titll'tt
.:.. tilt r. (}Il N�ii Ccmcnf Gmut t� licnlair lc CtitpS;or P�1tclS
;
OCer�tttrm�lit cntm ?(`aahn 'Simply). }�Rcsidcnllnl IS Saix[Ccnttal;�irout Drt Cti}
Dinili)sttiallCoitmtcn ial_; Ctitcstifenhal t4'aEci�utr�t},(stltnYt}; II Ca►'1Cn toGrnut II 1)tttl CtllllTt
CI Sp;ct3th GtU'iiT; II Gratel
ltna li�'atcr SuliPl}.�Vct(:;,; 1 Bert#oni[eIntt}'; : U Ottt�r'(c�lalairi u[xtcr'?g`j.
E&hSottrintte:, >�12"eto�•en.��
Anjcction\Nett.. •� ?f-For'cach niateriitt scicctcit�aGc►Fc,nirrii�c:intoint�uf tnatcralsuscd
IIAgtjft:rltccprge; Dtatouaditi-ttukCiitctitnTion,:, Neat Cem.:471b ,Wtr:3gal. Sand Cem.:lb ,Wtr:gal.
pAt�ufcr Starn�c atxi Ttc�:c�ti nr��. GtS`.►Itni14.t3 tmoc` ;
�JA ItIfee Tres' ©5lnnmt'itler T)ra►is e':
�C�p nntEntal Tn hunl� � IISnbsi.�ct�a Cutit ali t; Pl fig 11ti a tirtif dcscriptlna nfthc:il► h f1hmcnr j►n1t�tilul :,
CSG•otl{brutal(Gto��dT;eOp�. �tTr{cer: .: .. .
POURED W/TREMI FROM THE BOTTOM TO THE SURFACE
�1Gi.attttrlt�{t:(tie:{udstCoo#ln„Return)` nptl{vr(c� lalit w#dct:r.S ,
'!
1 nttestcU(5)mia 11P'I ti 10-29-22,.
Sa.�ircUs`Iuc:t{oli: i,
National Guard Armory J UriM
- S Ccrtliicatlprt:; t�tt'�I�J'a
I'alltiyr4w:5�r2•?;ttrit ' 1-51�{�t�N(tfippS,.+�1rIC)'. •. �
2000 Silas Creek Parkway, Winston Salem NC 27103 B:ri Ei 11/9/2022
Pii}sirai Adttres Cttt.' iidZip CtUlri:�s,l(islilkvl 1VC3{(4rnrr IUres r'll0+vr,:z,' ll:i(
Forsyth 131 vrtnitrt+*t{tre;(��tatr 1 hvibY cert Mat.41e tt r!t(sY was(ie�t4.u5nrirtvtt�r7 tt:
�uunti:,, 1 rrrt ld.ru,Ci llSnti Nu;(Fth uc[<,tlr nee t�itli'1�#�C%i U' 1{l ttr"f Uryt O:Ti ell ei�tisink ut+tt,hrn'.kmi..s
` ctrtc7lhiiY a rop}E�,f tlira rccrtt r7lrns�enr prnn,'rlc'c?On t/r�.ss�ll ulr/itr--
{h �,ailhldcarid Inns ttdc to 11c�rccslmin[+f�s/seconds orsTcclm d dcit+n.s � •, �
(rfxClT n lrl(eta lad tnusi� �t i>Fix} Site di;igIdllY i1 dlltt1t10n 1t�1411'ilQ[AnS;
tiou,tii3} lue[1r`b1�k.of Uu�4�b�to pratdc,addttienaE�tll-sae d�tais or cell
:ubatab ituen!details, a'_ou ma}'also.at[ach uclditio»a! a��s 1f ix�c�5an;'
r
f(1hCTttTt( {l(lY nF!',11I S()F�YFi 14"�11F Itl( AB lNpUi1 Fb ,NRIV11TT;1L.'T1�S i RLiC-T10YS,
�rtratr 'irrll cwrtilruelfan nri'.rrr�'j�/at.;n�l�lrri 1�ear tr ul�rrile u�cY7ut rnr rr+rn It#V'�trolllj'- - -
++eilrU,hL1 5r)rlr )�v7rtti{ciirrt,�rrfrt%v9urthtltyrti ruUtAtt adrttittrirrsn`: 70,i 'Fnr A11 itettc ;kiibnuf 4lie fctmi tii[tnia'•3tlla�rS ot'c4lltptElisan til'IrCll
G� w#.Mw-_3
lottn cntl9 tttc follp�ilnS
pLt, lnn of'%ti'nt&1t6Quarc -]tifortnab in Yrpccsstal;Unit,;:
f,17�14 ail Su�tict Gctt 1 tcr.I2a1�1},h,N"00461 :
1i1► 'Total t1c#111�[i1fY 32 (ft): - i
7tSbrrr inicttlon�3'i11c In 6dditltsu to�eWn►g tl folio to ih°address ut TOa;
ttro��;aho Salrilut ont cbpv of i.fnmt_iVttla o {aiif- r
2 _G;Borehole diameter
;,tbactdonntcnl ln;tti,,follow ins,-�
(id WatcctcFAA
et`hcton:gauacfni►flce : (it:) Dili,IunlSf'1VtttcrR�aoulresUu�eln►untllliji'ctiuuCmtrvT 'rtgr,eii
`_ lG3G Ata�l Scn7n('cAte►,.Iti11c1hh,n 27G'J9 IG3(,,
Gc Clutcr casing lcn�tt[;:{if l5ion n}: (tt)
T0c.;F�r W�tri ,nnl�:Q Tn1I ctinn��`ON In addidda to 9[xllnr�alie iornl lo,
the addr�ssZes); bat�..-also iiiit 01 30 dar s.of
conplctian af;tirotl`abiilontiscn to ttiNcYiitnl} ,liritl6 dcp►itlFtctst of tlic outttq
6t Tniiur;i151iitJta ling-!in�nh
t;« Srccn#irii;ITl([fktittn�'10
FartnGl�!tli: Ng>ilrCacolittaUe in
-.tln�t dfEn};ironersllrrlNalnratRass}uxcs•-Di%ision:ot �i,._eRcsaur s; Et�,rcct#s�t�us�'U13