Forsyth_Well Abandonment_20240529 (6)

'WELL ABANDONMENT RECORD For internal Use ONLY:
1Vcll Contractor Infor`ma(ti�on: � ) WELL ABANDONMENT DETAILS
�1y1 � 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(it well owner personally abandoning well on his/her property) well construction/depth,only i GW-30 is needed. Indicate TOTAL NUMBER of G
^�0 wells abandoned: 3
NC Ve11.Contractor Certification Number 7b.Approximate volume of water remaining in well(s): _(gal.) F•
YADKIN WELL COMPANY INC. FOR WATER SUPPLY WELLS ONLY: '`
Company'Na]lie o
7c.Type of disinfectant used: �O �P `
2.Well Construction Permit 0: (•) l•� l it
List all applicable well construction permits(i.e.UiC,County,State,Variance,etc)iftntown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): Op
❑Agricultural ❑M�unicipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets �p
❑Geothermal(Heating/Cooling Supply) f3•Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Ci'ay-
❑IndustriaUCommercial ❑Residential Water Supply(shared) 9.1concrete Grout ❑ Drill Chttingsv.'i,,r
❑(ni ation ❑ Specialty Grout ❑ Gravel t /; 1
Notl.-Water Supply Well: ❑ Bentonite Slurry ��t l �u
❑ Other(explain urtdef Z4
7Nionitoring ❑Recovery
:ai ction Well:
If.For each material selected above,provide atmou4t bf mat rlirl"s h§idf '.
-aquifer Recharge ❑Groundwater Remediation
❑t,quifer Storage and Recovery VA
❑Salinity Barrier
❑r,quifer Test ❑Stormwater Drainage
Cl.Experimental Technology ❑Subsidence Control❑Gcathermpl(Closcd Loop) []Tracer7g,provide a brief description of the abandonment procedure:
J
oGgQt prm,�l(Heating/Cooling Return):. ❑Other(explain under 7 �� Plats �'(�` � P�t7►p,
4.Date rvcll(s)abandoned: _mod �at �('00'\ , CkUA
fia.1Vell location: o
LAN W 00 C� ;l L IBC C'6(0 Ot 4-'tl� ft Pout o d a 5t Y
Facility/ wnerName Facility iD9(if applicable) 8.Certil➢ ion:
PI3 sircal�Address,City.and Zip L(B
gnature oCCer i ntractor or Well Own Date
y signing thi n. I hereby certify that the ive(l(s) ivas (tivere) abandoned in
County Parcel Identification No.(P[N) accordance with 15A'NCAC 02C-0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
'b.,Latitude and longitude in degrees/mimttes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
IT6��D� N $�y�a 3O W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Airache'ellcorutnlctionrecord(.c)iifavoilable. Fornutlriple injection ornon-watersupplywells —
QXLY:mit)rthe sane constnrcriotvabandonment,you can submit one form.
10a. For All Wells: Submit this form. within &,days of completion of well
6a.Wcll"ID`fl abandonment to the following:
f ' a Division of Water Resources,Information Processing Unit,
6b.Tot•tl well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For InleCtiOn Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: P40 (iu.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.1Waterlevel below ground surface: , (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c;Outer casing length(if known): _ (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the Z
address(es)above,also submit one copy of this form within 30 days of completion C
of well abandonment to the county health department of the county where (�
6f,Inner casing/tubing length(if known): _ (ft.) abandoned. t--\-`
�o
6g..Scrcen length(if known):
Q
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 e C