Forsyth_Well Abandonment_20240529 (5)

AXELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Informattiion: WELL ABANDONMENT DETAILS
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 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
1&0la -C
NC Well'.ContractorCertifcation Nuniber 7b.Approximate volume of water remaining in well(s): (gal.)
YDKIN WELL COMPANY INC. FOR WATER SUPPLY WELLS ONLY:
Company Naiife
4I/ lO/• 7c Type of disinfectant used:
2.Well Construction Permit h: r ( (�
List a!1 applicable well construction permits 0.e.UIC,County,State,variance,etc.)t(brown i N-
7d.Amount of disinfectant used:
3.Well use(check well use): `
Water Supply Well: 7e.Sealing materials used.(check all that apply):
❑Agricultural ❑Mun ublic ❑ Neat Cement Grout ❑ Bentonite GihiRs or k1l5
❑Geothermal(Heating/Cooling Supply) estItaft dent.]'Water Supply(single) ❑ Sand Cement Grout "''
__ � ❑ Dry Clay ' -• .
❑Industrial/Commercial ❑Residential Water Supply(shared) t;].c;oncrete Grout ❑ Drill Cuttings ty MAY �y (�J?4❑Irri ation El Special, Grout ❑ Gravel
Ntid-Water Supply Well: )r�.
01"Vionitoring ❑Recovery ❑Bentonite Slurry ❑ Other(explain uhii 71;1
J
'nicctiori Well: 7f For each material selected above,provide amount of materials used:
;Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier e
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
eo lied.` losed'Lv0 ❑Tracer 7g•Provide a brief description of the abandonment procedure:
❑G
t finalO p)
pGeptb."r7ta(.(•He0,ng/Cooli•ng Return), ❑Other explain under 7 ) Art
4 Cr
4:Date well(s)abandoned: ZS Z1Vl
ia.Well location: 1
12
/Q,0,
Facility/Owner Name FacilitylDH ifapplicable) 8.Certification:
Physical Address,City.and Zip. Signature of Certified Well Contractor or Wellell Owne
Date
By signing this form, I herebycerti that the ravel!(s nvas were abandoned in
Corpty Parcel Identification No.(PIN) accordance ivith 15ANCAC 02C:0100 or2C.0100Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
f dell Held,one IaVlong is sufficient) _ 9.Site diagram or additional well details:
J6 j 1 Z Z 7 411 1 0 N �Oi p!,� W You may use the back of this page to provide additional well site details or well
—� 6 abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructio record(.n)ifavailable. For multiple hnjecuon or non-water supply welts
Q,yLy.w n itIr the scone constntctionlabandonment,YOU can submit one form.
10a. For Ali Wells: -Submit this form.vti#bip.%Ni;dpys:of.completion of well
62.VVz1C117 : ' � K/1�(�l1 abandonment to the following:
` tf r : U Division of Water Reso.urcesi Information Processing Unit,
6b.Total well depth: / —(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iujectiou Wells:. In addition to sending the form to the address in 10a
6c.Borehole'diamcter: (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:.
6d.:-Watcr-level below ground surface: 30 _(ft.) Division of Water Resources,Underground Injection Control Program,
1636 A4ail Service Center,Raleigh,NC 27699-1636
6q Outer casing length(if known): qu (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form writhin 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(if known): n[ M. `
Fohn GW-30 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016 _
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