Forsyth_Well Abandonment_20231006

WELL ABANDONMENT RECORD ForIntemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David Hardy 72.For Geoprobe/DPT or Closed-Loop op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW 30 is needed. Indicate TOTAL NUMBER of
2906-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal
Aqua Drill, Inc. FOR WATER SUPPLY WELLS ONLY:
CompanyName
7c.Type of disinfectant used:
2.Well Construction Permit#: 4 ee '3 Q
List all applicable well construction permits(Le U1C.Cow,4y Slate,Variance,eta.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout f-; o:❑r$t:ntonite Chips or Pellets y
❑Geothermal(Heating(Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement GroutFi. mot `...1 C7�llryela
❑Industrial/Commercial ❑Residential Water Supply(shared) K Concrete Grout !+ Drill Cuttings
❑hri ation ❑Specialty Grout OCT
o Vravel
Non-Water Supply Well:
❑Bentonite Slurry s iY
❑Monitoring ❑Recovery Ilt�o; ::• { {•' Y'F-zJ-,Qthet{explain under 7g)
Injection Well: 7f.For each material selected agove,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation g! ,
❑Aquifer Storage and Recovery ❑Salinity Barrier b
❑Aquifer Test ❑Stomrwater Drainage
❑Experimental Technology []Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
/
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Are o&' t, / �I t,-<1, �r/ &/ -Ti(//"14 `f
e zt,e 4.
'
4.Date well(s)abandoned:
Well location: •'
F i�wnerNarnc Facility ID#(if applicable) a.Cc lion:
Physical Address,City,an ip Signature of Certifi%WeH ' ctor or Well Owner Date
By signing this form,I hereby certify that the wells)way(were)abandoned in
CLAY f Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been '
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
r 2 N �r U ��1 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.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple it jection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well rD#• abandonment to the following:
i' Division of Water Resources,Information Processing Unit,
6b.Total well depth:�ln�CO1/A,0/ (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
� '1 0 10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: �-!J (in.) 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 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (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
6E Inner casingltubing length(if known): (ft) abandoned.
6g.Screen length Of known): (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016