Forsyth_Well Abandonment_20230818

WELL.-ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contract r Information: WELL ABANDONMENT DETAILS 71
( 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Rtell Contractor Name( r well owner pers pally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of tZ7
24^ wells abandoned: r-r1 .
NC'Weli Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '(gal.) Z
YADKIN WELL COMPANY INC. FOR WATER SUPPLY WELLS ONLY: U
Company Name Z
(/� 7 77 7c.Type of disinfectant used:_. h1t5 t'l/Ug_
2.Well Construction Permit#: l CA
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if knouw Q
7d.Amount of disinfectant used: Oz.
3.Well us'e(check wcll use):
)Vater:SuP.ply 1Ve11: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Afffesidential Water Supply(single) ❑ Sand.Cement Grout ❑ Dry Clay t)
❑Industrial/Commercial '❑Residential Water Supply(shared) ,'Concrete Grout ❑.Drill Cuttings
❑ . i ation _ _ n+ Specialty
.Grout 4 Gravel
Non-Water Supply Well`a`::s. "..,., :. , tp� _
t. � &� Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery 1
Injection Well: 7f.For each material selected above,provide amount of materials used:
i'. BUG 8 20Z Cn
❑Aquifer Recharge -❑Groundwater emedtation 7
❑Aquifer Storage and Recovery ❑Salim to ZR
❑aquifer Test ❑Stormwater Drain a�gg �
❑Experimental Technology ❑Subsidence Control m
JGeotliermal(C(iised.Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
. .
rI0 othermal(Heating/Cooling Return) ❑Other(explain under 7g) (rC✓v+o�a�w n!u .n i r��d E l iera t� lnC J d
rBF ftay deb etlr� Q1✓c� 120Lie, p
4.Date well(s)abandoned: pS �• V
Sa.WcilLL•locatioti: 3�Ll— �l K?' �G T� ,. .: ... , .. 1�`
•'F 4iliry".YQKtj y-Na`iiie :"'"`" ''" Facility ID#(ifapplicable) 8.Cert;i ion:' b�l
`. ,
Physical Address;City,-ant-Zip Signature ofCerti 11 C actor or Well.Owner'.t: Date efJ
of : �., By signing this form, I hereby certify that the ivell(s)was (were)abandoned in Z
CouJrty: ;"' -. _ _ Parcel Identification No.(PIN) accordeince with 15A NCAC 02C.0100 or 2C.02t70'Well Construction Standards
" and that a copy of this record has been provided toile well'oivner.• -
5b.(Zatitude and longitude in degrees/minutes/seconds or decimal degrees:
(if%I ell,field,oitelk/lbbgg is sufficient) ¢' 9.Site diagram or additional well details: :•,:r ::.. ..:.
AF 0 31 9L N f��l 3 75-f 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..
�Jr+
CONSTRUCTION DETAILS OF WELL(Sl BEING ABANDONED SUBMITTAL INSTRUCTIONS. p(�
Andchu,ellconstructiourecotd(s)ifavailable.F.ot•niultipleiijectionornon-watersupplywells
ONLY with the sonic construction/abando"nent,you tali submit one fort".
10a. For All Wells: Submit this form within.:30 days of completion of well
6a.Well ID#: abandonment to the following:
li Division of Water Resources,Inform ation.Processing Unit,
6b.Total well depth: `1 {p A) 1617 Mail Service Center,Raleigh,NC 27699-1617
tl 10b.For Injection Wells:. In addition.to.scn_d.ing the•fQi:m,to_the.address in 10a
6c:BorchoWdiameter: � (in.) above,also submit one copy of this form within 3p.' ays:of completion of well
abandonment to the following:. .
6t1 1�Yxfcr'tlevel'6elow ground surface: v (ft.) 'Division of Water Resources,Underground Injection Control-Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known)': (ft.) 10.c.:For Water Supply&Iniection Wells: In addition to senging 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
611 Inner casing/tubing length(if kd6wn): (it.) abandoned. .• ,
6g.'Screen length
(len f known):,e.. g • ). (ft.j
Farm GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016