Forsyth_Well Abandonment_20230428

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor IIn�formation: 1 f WELL ABANDONMENT DETAILS
RQJAr., [ y��(1�e—k05� 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same !
Well Contractor N or well owner personally abandoning well on his/her property) well construction/depth,only I GW-301is'needed. Indicate TOTAL NUMBER of
wells abandoned: i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
n n e tw FOR WATER SUPPLY WELLS ONLY: ff�
Company Name J / i
7c.Type of disinfectant used: /-7 0 f l 7-1
2.Well Construction Permit#: 140 14
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: �C3 CTZ- 4
3.Well use(check well use):
Water Supply Well: 7e.Sealing mat r1sF�Sr�erd-(crhe pll that apply):
❑Agricultural ❑Municipal/Public ElNeat Cement I'irbtit-- 1[ entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 24-sidential Water Supply(single) ❑ Sand Cement Gro t p ry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) CO'Concrete Grout PR 2 82023 ❑ Drill Cuttings
❑lrri ation ❑ Specialty qR pr,,,s t❑ Gravel
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Non-Water Supply Well: ❑ Bentonite Slurry `LV�bther(explain under 7g)
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❑Monitoring ❑Recovery a !
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑A uifer Recharge ❑Groundwater Remediation P A S
❑Aquifer Storage and Recovery ❑Salinity Barrier
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❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Qf
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) I fun'h r`` tlYr� �X�C'ry r�� 'UT 1
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i ^ Li hU i_Je��t / J llnD Ea j,��je Well ll A i�C
4.Date well(s)abandoned: E/
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52.Well location: // r
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Facility/Owner Name Facility ID#(ifapplicable) S.Certifcation: S
Physical Address,City,and Zip Signature" We
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Certified Contractor or Well Owner Date
�2 1^i� G•w 41 By signing this form, 1 hereby certify that the wells)was (were) abandoned in
County _ Parcel Identification No.(PIN) 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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laUlong is sufficient) 9.Site diagram or additional well details:
ri v You may use the back of this page to provide additional well site details or well f
36, `��� N 3-0-mot-'244 W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS-OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUS T'IONS
Attach well construction record(s)iifavailable.For multrpleinjection ornon-watir supply 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#: 10 abandonment to the following:
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Division of Water Resources,Information Processing Unit, i
6b.Total well depth: �� (ft) 1617 Mad Service Center,Raleigh,NC 27699-1617 s
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10b.For Injection Weds: 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: s
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6d.Water level below ground surface: /t) (ft) Division of Water Resources,Underground Injection.Control Program, i
1636 Mail Service Center,Raleigh,NC 27699-1636
6e,Outer casing length(if known): Al P (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
6f.Inner casing/tubing length(if known): N 14 (ft.) abandoned.
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6g.Screen length(if known): X1/7 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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