Forsyth_Well Abandonment_20240529

WELL ABANDONMENT RECORD For intemal Use ONLY —
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David Hardy
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-3C is needed. Indicate TOTAL NUMBER of
2906—A wells abandoned: _
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): . 1-3 (gal,)
Aqua Drill, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name % 7e
013
1 3 �� / 7c Type of disinfectant used:-h-
2.Well Construction Permit#: �j ����"''TTTT
List all applicable well construction permits(i.e.U(C,County.State, Variance,etc.)ii(known
3.Well use(check well use):
7d.Amount of disinfectant used:
—_
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑ Neat Cement Grout ❑Bentonite Chips or Pellets a 2024
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustrial/Commerciai ❑Residential Water Supply(shared) ( Concrete Grout ❑Drill Cuttings .' ✓•`
❑Irrigation ❑Specialty Grout O Gravel L'•". =-'
Non-Water Supply Well: ❑Bentonite Slurry❑Monitoring ❑Recovery ❑Other(explain under 7g)
Injection Well: 7E For each material selected above,provide amount of materials used:
OAquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
OGeothermal(Closed Loop) ❑Tracer 7 Provide a brief description of the aibaudonrn t procedure:
❑Geothermal eating/Cooling Return) ❑Other(explain under 7g) � (�
4.Date well(s)abandoned:
ff �r ! + I S rarer/ V/ f ZZA o e e-
a II loca' n j —T
Facility/Owner Name Facility EM(ifapplicable 8.Certifica'
n r
P yifie�l Address,City, d Z�j4 •� rL..+�i //�! f
(G!/ Signature o ertified Wdl Contractor tell Owner Date
ounty By signing this form, 1 hereby certify that the well(s) was(were) abandoned in
Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy ofthis record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well dtatails:
N � 2 r/J W You may use the back of this page br provide additional well site details or well
t— 7 abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED
Attach well cmubvctimi rerord(s)ifavailable. For multiple byection or non-watersupply wells SUBMITTAL INSTRUCTIONS
ONLY with the same constructionlabandonrnent,you can submit one form.
10a. For All Wells: Submit this loon within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:_—A2-00 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Iniection Wells: in addition to sending the form to the address in 10a
6e.Borehole diameter. (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following.
6d.Water level below ground surface: .3 11-0 ) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e,Outer rasing length(if known): (B_) 10c.For Water Supply&injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft-) abandoned.
6g.Screen length Cif known): (g.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016