Forsyth_Well Abandonment_20230825

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information:
WELL ABANDONMENT DETAILS
David Hardy 7a.For Geoprobe/DPT or Closed-Lo'op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW,130.is needed Indicate TOTAL NUMBER of
2906—A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):--a_(gm•)
Aqua Drill, Inc.
FOR WATER SUPPLY WELLS ONLY:
Company Name
g 7c.Type of disinfectant used: a
2.Well Construction Permit#:_'3
List all applicable irzll constructionpermits(e.UIC;County,Slate Variance,eta)ifknomn
7d.Amount of disinfectant used:
3.Well use(check well use):
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Water Supply Well: 7e.Sealing.materials used(check all that apply):
❑Agricultural ❑Municipal/Pablic ❑Neat Cement Grout i ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) "Concrete Grout ❑Drill Cuttings
❑n- ate ❑Specialty Grout ❑Gravel
Non-Water Supply Well: P Fjentonite Slurry
❑Monitoring ❑Recov i �Y ;, ❑Other(explain under 7g)
Injection Well: CC 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GrouudwaterA di%ions 2023
❑Aquifer Storage and Recovery ❑Salinity Barrier ,
❑Aquifer Test ❑StommAte l,Pcp
❑Experimental Technology ❑Subsidence Control nd �/
❑Geothermal(Closed Loop) ❑Tracer 7g. rovide a brief descciptionof the abandonment procedi 7e: r✓W ( `
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❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
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4.Date well X3
s)abandoned:
Sa.Well location:
Facility/Owner Name Facility ID#(ifapplliicaable) & cation:
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Physical Address,dti,and Zip
Si ofCertified Well C ctoro el O r ate
By signing this fonn, e y certify that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.01 1.00'or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwcll field,o_ at/ ng is sufficient) /�/� 9.Site diagram or additional well details:
v G'l v N ?l(/t y'.,7 7] W You may use the back of this page to provide additional well site details or well
f� abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavallable.For multiple bdecdon or non-walersupp/v wells
ONLYwith flue same constructionlabandonment,you'ean submit oneform.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well Mff: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (m,) 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: Aft) Division of Water Resources,Underground Injection Control Program,
1636 Marl Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft•) 10c.For Water Sup Iv&Infection 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): (ft.) abandoned s
6g.Screen length(if known): (fk)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016