Forsyth_Well Abandonment_20220530

NMLL ABANDONMENT RECORD For Internal Use ONLY:
1. Contracto Informati n: WELL ABANDONMENT DETAII.S
aJ� 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
a-0 31
wells abandoned-
NC
ell C tractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
,)—- 1,�`If-I q e• FOR WATER SUPPLY WELLS ONE t , m$ 1 V B J
Company Name 1 F
c Type of disinfectant used:
2.Well Construction Permit#: 7
Y 3 U 2022
List all applicable well construction permits(i.e.VIC.County.Stale,Variance,etr-)ifbrown -
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Searing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Iieating/Cooling Supply) ifesidential Water Supply(single) ►Sand Cement Grout ❑Dry Clay
❑industriallCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
01ni tion ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation a+�Re�S
❑Aquifer Storage and Recovery ❑Salinity Barrier —i'
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief 1descrinption of the abandonment procedure: 1
❑Geothermal(Closed Loop) ❑Tracer ciye A A'tu�Mb1pq _( zom W-( 1`
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) a"' ! �1�
_ _ Ch 1o?-X AAA' well I H tIeA g el t wt+
4.Date well(s)abandoned: M��• 1 P���i�q W A'�e 2
5a.Well location: �
.( �r' '1N� � 1 •��'Du9� l(�1-e V%P� 136
ROAPJ CAP.
kitr � P Oeta��1PA�` �J� Sa Q�J 1 •
Facility/Owner Name F cility W#(ifapplicrble) 8.Certification:
plc. Qajc 4awav\ 0'q =
Physical Address,City,and Zip _ a 1 l D3 Signature of Certified Well Contractor or Wcll Owner Date
By signing this fornt,1 hereby cerlify that the ivell(s)tvas(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a cop},of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds ordecimal degrees:
(ifwell field,"on`e harlloonngg is sufficient) Q 9.Site diagram or additional well details:
3 ►d1 J I N v O ���-1 5 4 ly You may use the back of this page to provide additional welt site details or well
abandonment details. You may also attach additional pages if necessary
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifmailabla Forinulliple injection ornon-watersupply wells
ONLY with the same constructionlabandonment,you can submit one form"
10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#' abandonment to the followin--
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1-7 2r (ft) 1617 Mail Service Center,]Weigh,NC 27699 1617
b
f 1 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.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 </ (fL) Divisiowof Water Resources,Underground Injection Control Program,
1636 Mail Service Center,(Raleigh,NC 276994636
�l
6e Outer casing length(d known): (ft) 10c.For Water Supply&Iniection 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
6L Inner casingitubing length.(d known): (ft); abandoned.
6g.ScreenItingth(if known): (ft)
Form GW 30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016