Forsyth_Well Abandonment_20231122

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WELL ABANDONMENT RECORD For internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS!
A 1.b$Q n 11;), {1v2.S -( f`q„('" 7a.For Geoprobe/OPT or Ioop Geothermal Wells having the same.
Well Contractor Name(or well owner personally abandoning well en his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
1.4 TA:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s); 33 (gal.)
N
FOR WATER SUPPLY WELLS ONLY:
Company f-A
ma c
7c.Type of disinfectant used: 5'0 ha HTj-1 Lli IOC ile_
2.Well Construction Permit#: FtIs-# 3 w •Ll i.-4-1-
List all applicable well construction permits(i.e.UIC.County,State.Variance.etc.)if known 1
7d.Amount of disinfectant used: . d8 67
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural OMM/unicipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
OGeothermal CReating/Cooling Supply) laResidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
:Olndustrial/Commercial ❑Residential Water Supply(shared) 5/Concrete Concrete Grout 0 Drill Cuttings
-__ - ❑irrigation: 0 Specialty Grout 0 Gravel _ ---__
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
OMonitoring, ORecovery
`Injection Well: 7f.For each material selected above,provide amount of materials used:
OAquifer Recharge ❑Groundwater Retnediation { r .,r r
•OAquifer Storage and Recovery OSalinity Barrier
OAquiferTest OStormwaterDrainage _ NOV 2 2 .2023
0Experimental Technology ❑Subsidence Control 7g.Provide abrief description of the nbandonment rocedure: .
❑Geothermal(Closed Loop) OTracer g t'• Ins i77 ri`'` ',n, til;:i
..0Geothermal(IIeating/Cooling.Return).. .00ther(eicplain under 7g) tOMagi, FA tIrI, GYt�O(1Ct4•Ce.,1 `ilecl'rls`4sfl
'fie.-11 >41.4 wcl\ r:x- c.o.r.,k., <'cmo,4 cc*i,r1 ..
4.Date well(0)abandoned: 1.1 "9-ana3r ,t
4 d\.in r 0Un� Cdrir,- G.4 1 C.'6.en:.erll U>�•
5a.Well location: t
4
fijt r...q, eLrriS ,
Facility/Owner Name Facility 1Dii(if applicable) 8.Certification:
41144 4 cslca WI os-fan QJ. K Ct sllsvilL- a3 r) 4 W - - 11 `t
Physical Address,City,and Zip Signature of Certified Well Contractor or ell Owner Date
f- ('5� !v ! '55-49 Bye signing this form. i hereby certify that the well(s)was(were)abandoned in
County Parcel Identification Na.(PIN) accordance with I5A rVCAC 02C.4I00 or 2C.0200 Well Constnwtion 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:
(if well field,one 1st/long is sufficient) 9.Site diagram or additional well;details:
o You may use the back of this page to provide additional well site details or well
i`�n. (pt��Cl O N t.3a � W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS.
Attach well construction recor•d(s/ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a.For-All.Wells: Submit thins form within 30 days of completion of well
6a.Well ID#:, _ - abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For lnlection Wells: In addition to sending the form to the address in Loa
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: p`Zd (in.)
abandonment to the following:
6d.Water level below ground surface; (.3 (ft.) Division of Water Resources,{Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): C33 (ft.) 10c.For Water Sootily'&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
abandoned. I.
6E Inner casing/tubiitg length(if known); A 1A (ft.) I,
6g.Screen length(if known): fl A (ft.)
Fenn GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016
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4- xO42'a FORSYTH COUNTY HEALTH DEPARTMENT
.,.. '� Division of Environmental Health
m °' P.O. Box 686, Winston-Salem, NC 27142 P 1 ht I* �fr S-5G=4966
p z 336-703-3225
�,, . , ! File Number ON/1-9-
Lot4s, Block. 639
WELL ABANDONMENT RECORD
Contractor._ n ' Registration No. 111A
Well Location:(Show a sketch of the site at the right on this form)
6.6966'4 9 o t•1
e;0. 139.391°W
Owner A.tCosa" N. ( c.r-r‘4
---site-Address i#H�1-4 bt e1—ih1;as ian—,rri----- SITE DIAGRAM
t' e;r evsv4(:- ;t;rc: l 4 e, •
Topography: draw, slope, hilltop, valley, flat
Use of Well sp,o Date
Total:Depth 33 / Diameter ao" {,
Casing Removed:
Feet Diameter
3. 5.' ao`'
Sealing Material:
Neat Cement Sand Cement
A
bags cement bags cement I:
We."
gals water yds sand
gals water
Other: 1 q'
Type material ( crt✓• We-If Aloe Nk
Amount \ no tm�
Ni
Explain method of emplacement of material:
eRaPPANA.....#i:AQ1+1 \n5 3 C44 t 0.c;tea cJ,
+ s 46 . cc.s:. C,t0 .L-t1
it
.. P XAN.ac t tom} cp 4 cJ 04 '
I do hereby certify that this well abandonment record is ,
true and exact.
cloorbip. 424407zi .„.
.Signature-Contractor/Owner Irr:. Date j
-11r P--€bts II a 1.
Sigt • r', S. tlea.. a ;2.' OW U O +On 120c.“J
COPIES:WHITE—HEALTH DEPT. / YELLOW—CONTRACTOR / PINK—HOMEOWNER Rev&Reset FCPS 1-22-2014
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