Forsyth_Well Abandonment_20240306 (2)

NVELL ABANDONMENT RECUR_D For Immal Usc ONLY:
This,form can be used for single or nudliple*11s
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1,Well Contractor Information: WELL ARANDONNIENT DETAILS
John Eisenman 7:L Nttmherof�rcllsheingalrandan I9:,1
\Vc11CotYrvcrortvalttc or.}tielluan� cull tl�ntortiu;tteilonhisfircr rtl. For Atlople f+Jwkur or wn-uwe lairlo- wells ONLY crab ilk Brune
t
cnrufrtrcnrxr•ir8anlivou�gar,yam CCU?s+laiarwiefirm,
4439A
71►.Approkima-to III me of w, retmtaiupig in irell(s}0 („ui)
NE rycq CnnlradorCcnificnlion Nvti>bcr I. ,
SAEDACCO FOR WATER SUPPLY WELI.SONLY. v
76 Type of disink tart,used:na
2.}Yell Construction Pernrlt 4:, MAR Q ii 2uZ4
Ltet 41 uppluwbie uWllur+eils(i.e Can!},Stcte,J'urrun r.Llectinr;..tc}ork.sr+ 7d.Atniinnt of tils[nfcefant`trscvl'. ' �I1
3.NVdi use(check hell nse):
Water Supply Well: 7c.Sealing materiws:tt3ed(cocci:all ells.[apply):
17etgrccultitral: plvtunicipaUPttblic' 13 Ncat Ccrucut.Gtout ❑Hcruotlitc Chips orHict's
nGcothcnnal(HcitingfCooling Supply)" Qltcsiaauial WatcrSupply(single) O Sandfierrrcnl Grout O Dry Clay
❑bldlasfriallComntcr¢ial ❑RcsidentialWatcrSupply.-(sluued) E3 CaudeteGrou-t 13 DtillCuttings
Obri .ion 17 5peeiafi}Grout ❑Gravel
NQuAVaterSupply Well.- d HentoniteSluay 13 other(esplainunder7g)
smanitorine ORecovety
Injection NVctl: 7f.For each tmatetial selected above,pirutide amount of.nuitedals u'scd:
OAquifer.kCharg6. L1Gtouhrl alerRentediation
0Agnifer Storage and Recoverir LISalin4 l3arrier ;,
OAgoiferTest OStonmsnlerDraiiiage
. Bentonite.:401b ,Wtr:gAl. +
OE.yrerintetual Tlechuotgn aSubsideote Coniinl 7g:Provide a brief descriptian of thc.aliandanrrtent pp!cedure:
DGeothenuat(Closed loop) 13Tracer
pour pellets down well-pipe from surface. checking depth
❑Geothemiat(Heati4elCoolin Retum) Wther(e\ lain under7,)
periodically to ensure pellets are falling to the bottom
d.DatC R'e1i(s).ab 1n(lonecl:2-6-24 until pellets reach surface
Sa.Nell tncation:
Omnisource
Facilit?+arvrurNM= Failiq IDA+(ifappliwbrc? $�GCtlllTcatiQil:
1426 W Mountain St., Kernersville, NC 27284 - 2/22/2024
Pltysical Address,City,and Zip !, -- 1r+iY``c._lo.ts.-ess .._e•�x. ,rrrwr I?ate
Forsyth By si ning this•M.: '' �z:hJy.rlirrr the irellfs)a-as 6verte)aharidoned in
County Pxrd lit ntltii idanNo.(PINT acwtdatice wifo IJIANC.4C OZC,010tl.ar3C:0200(fell 6- ;Wizfction Sti nck+rds
mid drat amp},ofllris record kasheeir provided to drei ell ouuer.'
5b:1 Latitude and l angitude hi ttegmshulltuto iscconds'or deciutaNegrasi
(iftiell r.;ld,011C larltttng it s„111cuti) 9.Site diagram or additionat well deals:
You tuay use the bael:of this page to p'roGidla additiotlal rrkll site details or hell
.abandountentdetails..You tuay also attach additionatpages if nec essar31-
CONSTRUMION DETAILS ON WELIA:S`1 BEING ABANDONED SURNMTAT,TNSTRT[TCTtO7X4
:tftf7th dell GY/RYIf1lCtlrlrl riCTJrfl{yf lj dNQlllLrJIC Ftir tmrinplr i�g'rctinrr'tif'rxln•Icuti7'slrpplt
ur1Ls QlYLX v'itli die saute rvlrsnverao+r u5nrrebxcrer+c uu cnn JJrbmlt wrelunrr Ma: Nor All Wells Submit tires tamt within 30 days,of completion or•u-ell
6s.%Yell ID#:
CPT-09=25. abandoorncnf tothrfallo'ving:
Division of NVaterRrsanrecs,information ProcL-Wu;Unit,
Gb.Totat'tt'cll depth: 25 (TL) 1617 X-01 Seinicc Ccritsr;Ralcel ti,NC 2769946t7
lOb.For dalecllon Wells: In addifioii to sending the form-to the address in IN
aboia.also subadt one copy of thisfon within 30 days of completion of well.
6c.BeICI►ole diarneter.2 011.y I
:Ibandoumerrt to rlte follolrillg_ i
641.Water level below ground surface-"15 (ft.) Divisiott of Water Resources;Underground Injection Couttiol Prdgratn,
1636 Mail Service:Cckcr,RalciA,NC 276'19-1636
Er.Outer caairt length if lmofl a): 00 10c F'nr Water Strnnh• 14 ihieetfoio M11s: In addition td sending the form to
g '( the addresses) abode. also subtuit lotie copy of this form.iAtltin 30 days of
cornptetiari of W'di'abandoirment to�thc county Itealtit depailment of the county .
Gf.Inner wsiaj�tnbint turj,Kb(if lvawn)r 10
where abandoned..
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6g.Sued..length(if la ouv):15 (ft)
Foim Gt11-30 Nonh Camllm Ikputrrnm ofPnviroatnent mx1 Narumt Itesouxcs-I}Iris[on of WarcrRcsoluns Revised Auprsa 20t3
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