Forsyth_Well Abandonment_20240624 (2)

i M L ABANDONIIMENT RECORD —
1.Well Contractor Information: For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a.For Jamie Neugent W Geothermal Wells having the same
ell Contractor Name(or well owner personallyabandoning well on his/her roe well construction/depth,h,only 1 GW '�0 iiT or sneeded, Indicate TOTAL NUMBER of
g property)�')
2677-A wells abandoned:
NC wen contractorCertiftmation Number 7b.Approximate volume of water remaining in well(s): csah)
Aq u a D ri l l Inc. FOR WATER SUPPLY WELLS(ON LY:
Company Name
��1 �3
2.Well Construction Permit q:J`-���' � y�� .� 7c.Type of disinfectant used: L6
List all applicable well construction permits(i.e.U1G County,State.Variance,etc.)iflmown
3.Well use(check well use):
7d.Amount of disinfectant used:_1/o 1/0 Z 6
—
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑AgriculturalPP y)'
,;,A icipaliPublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) es)dcntial Water Supply(single) ❑SS d Cement Grout ❑Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) 7Conctete Grout ❑Drill Wings
01hriatition ❑Specialty Grout ❑Gravel
Not.-Water Supply Well:
❑Bentonite Slurry
❑Other(explain under 7g)❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge 00roundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier --
❑Aquifer Test ❑Stormwawr Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
[]Geothermal(Heatin Coolin Rehun) ❑Other(explain under 7g)
4.Date well(q)abandoned:
Sa.Well location:
Facility/owner Name Facility 11.E(ifamlicabie) S.Certification:
311510 Riles 1i/1AKc 3. Al �tl L 2 17 f JS
Physical Address,City,and Zip Signature of Certified Well Co.=.,or W,: ate
County By signing this farin,I hereby certify that the well(s)was(were)abandoned in
Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0107 or 2C.0200 Well Constnletion Standards
Sb.Latitude and longitude in d and that a copy of this record has been provided to the well owner.
(ifwelL seta,one IaLdon i sufficient) ee�tmnutes/seeonds or decimal degrees:
9.Site diagram or additional well derails:
164+,I g j N ,f�I � 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 WELLS)BEING ABANDONED
Attach weft cunsiniction recard(s)ifavailable.Formu/liple injection or non-water supply netts SUBMITTAL INSTRUCTIONS
ONLY with the same construction/abaadnnmead,yuu can submit one jnrm.
102. For All Wells: Submit this form within 30 days of completion of well
6n.Well ID#: abandonment to the following:
Division of Water Resources,!information Processing Unit,
6b.Total well depth: � ({t,) 1617 Mail Service Center,Raleigh,NC 2769 9-1 6 1 7
f ,0 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter. '� (in,) above,also submit one copy of this fi)mt within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (ft) Division of Water Resources,Underground injection Control Program,
01 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): / (n) 10e.For Water Supply&Injection WON: In addition to sending the form to the
addres3(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 casingitubing length(if known): rl (ft) abandoned.
6g.Screen length(if known): d (ft.)
Form GW-30 North Carolina nenartment„tr—i— m —i n—m.,