Forsyth_Well Abandonment_20221216

DEC 1 .r 2022
:;3 Ijn,1
WELL ABANDONMENT I��n CORD For tmerml UseoxLY:
This form can be used for single or multiple wells
1.We11 Coa r "ArELL ABANDONMENT DVI AILS
7a.Number ofwells being abandoned.
%VeliCoauacterPrdme(orvcUq%ti=personal[pabandopiagucllanlasHterptapem} For mult/ple taJectton or nato-uarer supply uellc ONLY mith the Sanir
construction bhw1dtatment,Parr catimbmitaitg farm.
NC Well Conaactar Ceaifitation Number 7b•Approldmate volume of water reataining in well(s): l� (g2
Aqua shill, Inc. FOR WATER SUPPLY VVELLS ONLY:
Comantty Name 7c.Type of disinfectant used;
2.'rVell Construction Permit#:
List all applicable nrlipmidis(i e.Count}.5tatu.Crarimim Injecrioa.tar-)flimmi 7a Amount t7f disinfectant used:.4% 0>
3.Well use(chealrweli use):
Water Supply Weil: 7e.Sealing materials used(check all:thatapply):
OAgrieoltuml OM idpaMblic Cl Neat Cement Grant fl Bentauitt CbipsorPeliets
L1Geotheimal{Heatin�Cao)ing Supply) estdential Water.Supply(single) Sand Cement Grout 0 Dry Clay
IIIndustrioYCommercial OResidential Water Supply(shared) 12'6ontaete Grout O Drill Cuttings
Mrigelon ❑Specialty Grout 11 Gravel
Non-watersapplym,cu: O BentoniteSlutty ❑.Other(ecplaut under 7g)
❑Monitoring ORecovcry
Injection Well: 7E For eech material selected above,'provide amount of materials used:
C1AquiferRechaMe Mmundu-AcrRemedistion l f �0tiz't6, r
OAquiferStoni eandRecovery 17SalinityBarricr
OAquiferTest OStomnxaterDmina`e
OExpedinental.Terimcilqq OSubsidence Contras 7g.Provide brief description of the abandonment procedure:
©Geothermal(Closed loop) Mracer
IIGeothermal(HeatingiCoolmgRentm) OOdrer(explain under 7g) a a
4:Datewell(s)abandoned: ZAZ 1�2,-
a`a.Welllocation: �LGCr OG s� Gv/��r9<G
FaciMYRhvaarhame F=1ty1D9Gfapp1ieab1e)
�z�ti z�r�-u�-ODv�-�1 �F.���:aW�✓ ti�i�o � 2^ �- 22
PhysicalAd&=%lit};aadZp Slgaaaaeo CertifiedVV Con or ell0%%MW hate
By signing/iris fom.I hereby c-fify that 11te aveli(s)arcs(ivere)abandoned in
County Parml ldenimcatical"M(PRvy ai:w dmue whir 15A A101C 02C.0100 or3C.0200 Well ConmwctionStandmdr
and that a copy ajthisrecosdluzsbeotprovided to the ue11 corner
Sb.Latitude and longitude is degreestmirroles/secoad5 or decimal degrees:
ofacu field,arm lat!langis saffieieei) 9.Site diagram or additional well details:
A ,,�IU ,1q ird to��.s©�� ��� You may use the back of this page to provide additional ncil site details or Zvell
*�` abandonment details. YOU may also attach additional pagges ifnecessaiy.
CONSTRUMON DE i AELS MWE,LL(S)BEING ABANDONED gpgiyIl►'CAE,liVgCRiTCT1ON§
Atrntrlt well cautnrction retroxl(sj ijaroilable. h'nr rprthiple irrjeclian ar tiairtrater urpply
ue11rONLYrrLLJiesaorecarutnretiarrobrmdanmentyoucmtsubmironejorm. 1pe,For All Wells: Submit this''fornt within 30 days of completion of melt
6a.We1i I13"• abandonment to the following:
• Division of Water Resources,information Processing Unit
1617 Marl Service Center,Raleigh,NC 27699-1617
6b.Total well depth: M (ft) I
r 10b.For Injection Wells: In addition to sending the form to the address in l0a
above,also submit one copy of this form vtithin 30 da)%of completion of well
tic.Borehole diameter. (in.) abandonment to the foil
velbelowgouduracU� ��onofWateroRweisno�n rces,lUriderground Injection Control Program,6 Water IL
J636 Marl Service Center,lzateigh,NC 27699-1G36
i
10c-For Water Sunniv tic Iaieeti6n Wells: In addition to sending the fb,m to
do.Outer casing length(if(mown): (Ft)
the address(es)a6ovc,also submit one copy of this Fotm withins0 days of
completion of well abandonment to the county health department of the county
�vhcre abandoned
6{:Inner casingitubing length Of lmawnr (fyj