Forsyth_Well Abandonment_20230915

I
4
.
WELL ABANDONMENT DON1V'1t1G1'HT RECORD Far Intranet Use ONLY: •
This fart enttbe used for single ormultiplewells
1.Well Contractor Information: ..0WELL ABANDONMENT DETAILS .
ViligilaMOINVOinegli a 7 d fre /1( t((e'xn.Number ofrmlls being abandoned':'
Weil CanuacrorVame(arwellnu rpes angynb ndocinswanonhisliterpmputy) For multiple lnieettaa ar notrwarer supply mails ORLY with the sauce
am O"/C/' ti/1• ^ VET)
c t on obw:danmeat.your ouithrntYnnefothi.
7 C �.. ar
$ �° '^^ ' 7b.Approximate volume oflvater remaining in wcll(s): /7a (gaL)
NC Well Contractor Cettificin7tinidundm 1
Aqua Dill.Inc. SEP 1 & 2023 FOR WATER SUPPLY WELLS ONLY: pp��
CompanyNatnc. r ... .�ja�,; .�;p 1JI 7c.Typeofdisinfectantnsed: ` I/e'7o 'o
2.Wcf Construction Pernnt# itf j �O ' ••y�
Lfstall oppflcableaell peradts(Ee.Camp.Sale,irarimme.Nertlor,eta)Omen7d.Amount of disinfectant used: ' _ ®dam
3.Well use(chectcwelt use): ,
Water SupptyWell: 7e.Sealing materials used(check all that apply): '
['Agricultural • OMunicipallPubiic a Neat Cement Grout , CI Bentonite Chips or Pellets
CiGeodietmat(Heatine/CoolingSupply) idcntial Water Supply(single) Cl SSwid Cement Grout a; 0 Dr Clay
Clindustriel/Commereiat 011esidential Water Supply(shared)- g 6tmQete Grout 1 . Cl Drill Cuttings
['Irrigation - 0 Specialty Grout 1• ci Gravel .
Non-WaterSupplyWell: Cl BentoniteShiny 1, O Other(explain under 7g)
ONlaaoring [['Recovery71 For each material selected above,provide amount of materials used.
Injection Well: '
[Aquifer Recharge t7Grourid:tatcrRemediation LJ! 'AI eef,44 4
OAquiter Storage and Recovery °Salinity Barrier
°Aquifer Test CIStonawaterDrainage
['Experimental Technology ['Subsidence Control 7g Provide a brief description of the abandonment procedure: '
QGeothermal(Closed Loop) CITmcer
/a l w/ridist,o edeA !gib t'wGf it.404i c��G C
DGeothermal(Heating/CoolingReturn) Daher(=plain under V f.
4:Date wcit(s)ahaadottcd: � � 31 cAesi 4' Goc -rz-s ,G
5n..Velllocation: Pra(j G OU&.L Lv� ,�-fJ -,L
u c 4,O•yM,iPi�.�i�rJd�-S1/71G4 C/.UU
s 0/
Facilityl0Nams Facility}DR(ifapplieable) S•CertiScation:
aracr
/( Gd�oI 4 c r.�L<.6�t,,r�e�,i1IGLL- 2.72 a'to :°Lc l3 2''.3
Physical Address,Cny;and Zip of Muffed Contactor ortiVcll Owner
I 4L6'7 74 By signing this form,I hereby cerijt that the well(s)was(were)abandoned in
County Parcel identificationNo.(FIN) ai:cardance with.15A NGIC 02C.0100 of 2C.0300 Welt Construction Standards
and that a copy of this record has been provided to 11wweii owner,
5b Latitude and longitude in dcgrees(mimttesisccoads or decimal degrees:
(ifwe l Held,oec Wangle sufficient) 9.Site diagram or additional well details .
i You may use the back of this page'to'provide additional Weil she details or well
wt•/t0O5/ N go'.. 'fl d7 W abandonment details.You may else,attach additional pages ifnccessary.
CONSTRUCTION DET AILS.OFIVELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Artaeti well cattirtmtion merge)f ataflnbfe. For maniple injeulimi or non-water supply
wells ONLY rah the same alusintclarabundammentyouaonsubmf'oticform. 10a.For All Weill Submit this than'within 30 days of.comptetion of well
6n.WcR IiI� abandonment to the following: l'
S Division ofWaterRasources,Information Processing Unit,
fib-Total weil depth: 7 (ft.) 1617 Mall Service Center,Raleigh,NC 27699-1617
106.'For Infection Wells: In addition to sending the than to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c Borehole diameter: i'g (ill.) abandonment to the following: f
. A
Division of Water Resources!Underground Injection Control Program,
6d.Water level below ground surface; (ft) • 106 MaitService Center,Raleigh,NC 27699-1636
10e.For Water Suonly&Infection Wells: In addition to sending the form to
fie.Outer casing length(if imown): - (ft.) the address(es) above,also submit tone copy of this form within 30 days of
_ completion of well'abandonment to the county health department of the county
where abandoned. ; ; -
6E Inner casing/tubing length Rhone a): (It)

•
-
WELL MAMBO 11 NT RECORD, per gamma use oNLX: :
This form can be used fersingleor multiple wells .
i.Well Contractor&tram natiau: t //� WFT,4 ABANDONMENT DETAILS
Regginfteitangila v PGA' —
,5t/J ..Number ofrwel%sbeing abandoned: /
\Vet[CammaarName(avail avrempesaanliSalrandomag well anhisli:erpropem) Far =dupla flatten ar cremator supply was ONLY frith the same
cmrstnrcuan abandatmrant,}©u carrsrihrmY nrrafaim.
C9 t 1. C 1,.a Q i1 76:gpproximatevolumeGrunterremskiinginwell(s): ,1��D
NC Well ContractorCatifiauionNatber Y v� (gal.)
Aqua Drill,Inc. S F P 1 5 7073 FOR WATER SUPPLY WELLS OIV1 M
CampaicjNama r 7c.Type of disinfectant used: A,�/O h%Al
Z� ... n Pr:-.C:;.w'V::1 l.t:h
2.Well ConstrucansPermle ��,�. -�-.
List allcpp11ea61oar0prraatsreCowq State,Varmace.bJcaicnitc}(/?lawn 7d.AmouDtef disinfectant used: /Z a Z
3 Well use(cdeehwclf nse):
Water Supply Well: la Sealing materiais used(dwelt all that apply):
°Agiculturai a, .„-dpolpablic 17 Neat Cement Grout 0 Bentonite Chips orPellets
OGeottennal(Rcatin lCoolingSupply) u' ideal,!Water Supply(single) pad
Cornea Grout 17 Thy Clay
DIndastriaUCommercial °Residential Water Supply(shared) Concrete Grout C Drill Cuttings
°Irrigation 0 Specialty Grout i °Gravel
Non-Water SupplyWelb. C BentoniteSlu
°Monitoring °Recovery Slurry a O (espfaintmdrr7�
injection Well 7rr.For each neneriat selected above,provide amount of materials used:
[Moldier Recharge °Groundwater&mediation 4 ll#/z-i5°.! e4A.Pc. 'r
°Aquifer Storage and Recovery °Salinity Barrier
DAgniferTest DSto materDminage '
°ExperimentalTechnology ['Subsidence Control 7g Provide n brief description of the abandonment ptocedorm
°Geothermal(Closed Loop) t7Ttncer
°Geothermal(HeatinglCoolingReturn) DOther(eicplainunder7g) gC-�?/uGd �c c.s4 61/�/J��J jf� f�,�j,
7 T41,s.4 iPti i� 0 d( T6H1 cm ce4,•w/c a g-v-0�,zG
4:Date well(s)arbandoned: 9/7/2J AA#140'v6�1 3`Glijeiut ) Ala oudel-
k
a.Well location:
Gt��s1 t �LrJ vil1fo/L.
�/4s7LC y GOme../070/ '0,,pq/GO if tiU. I /
S.Certi6mtocFailitylOwnerName FaetltylD9(ifapplieable) •
a S C cavo6s e`.k Ad2,eigesvir e! 2_7..94 , ,''7,-a 9l�r c- 9�`/y,
Physical Address,City.and Zip 5' ofCettified Well Conusetoror Well Owner path
A1l y?iii ;Isigning this fora,I hereby ore that!lie utell(s)leas(were)abandoned in
County Parcel ldeatifeationNo.(PIN) accordance wad:15A NOW 02C.0100 or IC MOO Well Canslraclion Standards
ab Latitude and longitude in.degreesfminntcsfseconds or decimal degrees: and 11ra1 a eopyofthisrecorrl has been providedlo&eme!l owner.
(tfwdi field.am laden issallsicag 9.Site diagram or additional wdl details:
3t',419 0 PT (> 9 Od72. Yea use the W back of
this page tahafm details of well
ahandenmendeln .Y mayalssoattcaddi additional painecs ,y..
CONSTRUCTiON DETAEL0 OF WELLS)SEEING ABANDONED SEIBMEI TAL INSTRUCTIONS
Attach well canrtrrrehann recerd(s)ifatdlable Farmuhiplc infix:Ian or nunatierstpfy
wellsONLPrriththasvntecanrtrrallewabandra►wm,yaucmrsnbnrhauefarati ISa.Per All Wells: Submit this farm within 30 days of completion of well
6a.Wc1iID#: abandonment to the following: f
Division of Water Resources,Information Processing Unity
6h.'6otalwell depth: �� t (R) 1617[ram Service Center,Raleigb,NC 27699-i617
iI
10b.•Por Walton WelLq In addition to sending the fort to the address in 10a
above,also submit one copy of this farm within 30 days of completion of well
6t�)Sornholediauiater: (In.) abandonmratto the folltiwing i ,
bd.Waterlcvdbelttty ground J ( D Division of Water Resources,Underground injection ConfrolProwam,
g • 1636Mar Service Center,Raleigh,PIC 276994636
10e.For Water Sunnly Sr McMinn Wells: In addition to sending the Finn to
6e.Outer casing length(if imown): (ft.) the addresses)above,also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the count}
where abandoned.
6E Inner casiueltubing length ofimowi* (R)