Forsyth_Well Abandonment_20231215

WELL ABANDONMENT RECORD
For Internal Use ONLY:
1. ell Contractor Information: ,t1 WELL ABANDONMENT DETAILS
U C ��/v 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hisAterproperty) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
1 o5? wells abandoned: j
NC W 11 Contractor CertifM- Number 7b.Approximate volume ofwater remaining in well(s): (gal,)
4 .V3. L, 1I(I' ��e.
9 FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable irell consintction permits(i.e.UIC,Connly,State,Variance,etc.)iflaloum
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Munici al/Public Neat Cement p-A^en
tonte Chips or Pellets
❑Geothermal(Heating/Cooling-Supply) ❑Residential Water Supply(single) ❑Sand dement Grout @ ❑D^Cla
b PPY) PPY( b f Dry Y
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout D F C 1 L Mill Cuttings
FEDAquifer
❑ Specialty Grout ❑Gravel
Supply Well: 1�Bentonite Slurry lfGle'Y- t%�i' )
QRecovery �v'�'•3`a`,'�Other(explain under 7g
ll: 7f.For each material selected above,provide amount of materials used:
charge ❑GroundwaterRemediationqorage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑Stomtwater Drainage f�5 I5ePA*_N_A_*
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer -_ 7g.Provide a.brief description of,thhe�abandonment`pioocedure:
❑Geothermal(Heating/CotilingRetum) ❑Other(explain under 7g) 1� 1� cz a" 1 �" >M of v u e m
4.Datew ell(s)abandoned:
Crop
Sa.Well location:
0,*
Facility/Owner Name Facility ID#(if applicable) 8.Cc tiftcation:
300 r� a 3
Physical Address,Ci and Zip W— 5�,'�M �? Signature of Certified Well Contractor or Well Owner Date
0544V a't a-7
County Parcel Identification No.(PIN)
By signing this form,I hereby certify that the irell(s) eras(were)abandoned in
accordance with ISA NCAC 02C.0100 or 2C.0200 grell Construction Standards
5b.Latitude and longitude in degrees minutes/seconds or decimal degrees: and that a copy.of this record has beets provided to the well owner.
(if welt field,one iat/long is sufficient) _ 9.Site diagram or additional well details:
36 a d'��3�� 50 o y2:�83 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well cansintctron recortl(s)ifarnilable.For mul iple h!ection ornon-watersupply weliv
ONLFipith the same consintctionJabandonnient,you can submit one form.
/� n 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 1 +►w O`l abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: r (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 `
l+ 10b.For Iniection Wells: In"addition to sending the form to the address in 10a
Gc:Borehole1diamefer: (in,) above, also submit one copy of this form within 30 days of completion-of well
abandonment to the following:
6d.Water•level belowground surfacer (g,) -Division of Water Resources,Underground Injection.Control'Program,
1636 Dlail Service Center,Raleigh,NC 27699-1636.-
6e.Outer casing length(if kn(iwn): (ft,) :loc.For Water Sunniv&.Iniection Wells: lin addition to sending the form to the
address(es)above,also submit.one copy of this fomi 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.
6g.Screen length(if known):
Form GW-30 North Carolina Department offinvironmental Quality-Division of Water Resources Revised 2-22-2016