Forsyth_Well Abandonment_20240306 (3)

WELL ABANDONMENT RECORD For lmcnWUsdONLY;
This form can be used for single or multiple ells
1.Wcti Contractor Information: WELL ARANDONh1ENT DETALLS
John Eisenman 7u.YumberU%%IIls being abandoneal: 1
1YzltConttaetor.Nar>tc(oryvrllosve�pssanallyaliainitinlsi;�v.11.on3dvllrcrtuuperly) For rrridupte oyevum( or on-ware- fstrp*, welds" ANI w•tNr ILA+ sane
' hHr3rrrrClltNl•i�P(I(NlnhRlr,Ir�ncmesnbnUft�nr�finir,
4439A
TIC!Yell Conlr�aorCcrtificadoti Natirbcr 7b.Anpmrintatc%ulu to of aratu crc n r hig in wellos)9
FOR WATER.SUPPLY VMLS ONLY: _
SAEDACCO �• .�.= cr+CC�
Conpan}Nanrc 7c Type nfdisinkeWntrigid:na 'r �� L_i..s4�E.D
2:Well Construction Permit 4:, ' MAti 0 u 2024
Ltsr all apt bible well yermltr g.a�_C,wretr,-5rae,t arise;v.h fookir:..erc►,Vjwwr, 7d.Amount of disinfecfunt u.%-d:
3:1!Vell use(ehecic Wee rise): ►T1 ahCPi3i:7FO; fnll*@W,49 VFW
Water supply weal: .7c.Scaling MAGI als:ascd(cbccle alt'dt tt apply): L`tRIL)r3G
l7Agricultitral: plVltinicip;tllT'ttl?lic ❑Ncat Cement Grout ❑Bcrakd Chips orpcllcts.
00cothcrtn•tt(Hca1i4Cooling Supply) Mcsiikntial Water Sirppl}(single) ❑Sarafamt iu Grout ❑.Diy Clay
❑hgttistrial/Cgmntctcial ❑Residentiat%Vntcr Supply"(sham!) ❑Couciete Grow 17 Drill Carting
l7lrri lion 13 Special!y Grout 17 GrAvel
Non-Water Supple Well: ❑Bentolute Stuap ❑Other(esplainunder 7g)
amarittoring ❑Rec:oven•.
lojcction Well: 7f.For each ttiatertal scicet4aboFr,PrOsidc amount df.ntatedats ur ctl:
❑Agrrif:r Recharge, 17Grottiuittaler Rentgaiadou
17AquiferSt4tagr utxi ttecroiery DS:dinity Barrier
❑Ailuifer Tess P]StomntvterDtuhia�e
Bentonite.:401b ,Wtr:gdl. ;
pE.yrerintwal Technology -OSubsidencd Coutal 7g grrr�fdc a betel description of thc'.aUaiidnntncttt pn►cctlun:
❑Geothenual(Closed Loop) ❑Tracer
pour pellets down well.pipe from surface periodically
CGeothertmt(Heatinei'Cootin Return) 00ther(mplain under 7g)
checking depth-with tape measure to ensure pellets are
4.Datcncl1(s).4hando'ned:2-6-24 reaching the bottom, continue process until pellets reach
5a.WO locr il'on:
Omnisource
Facilit}/Orvncr Numc Pacilit}IDN(ifapplicablc) 8:Ccrtif(catiotC
1426 W Mountain St., Kernersville, NC 27284 2/22/2024
Mysieal Addles:City.and Zip
Forsyth By si�tibig;llrr_ yes c�s;-Vrhf} !teat the ire11{-v)irds Ove„e)ahendoned in
Cautity Parcel I4arniCk itinuNo.'(PIN) acco►rhncue ie'illr ISit 1VC4 ,OZC,0100 or 2C:0200 fF'elfGWsliarclion Slnnrkmis
and flrirt aCopl'oflhiyrecord bwbeeir provided(a7lrewell owner.
SkLad(ude and longitudeindcgrccshuItmteslsccrtntisordecinjil-de roes:
(t!ticu SM,ow Li0ong to sitnleictit) 9.Site diagram or additional well&h.Els:
You ruay use the bacli of this.page to provide additional!sell site deCiils or well
N " W .ahandoutnetu details..You may also Much addiliotral pages if necessan%
CoNSTRUC'TION DFTAIL.S OF WELLfS)BEING ABAkDONE'D SURbill'PAL INSTRUCTIONS
:tllarlr n:ell crir amellorl meord(s))f arm11ra41a A.mrtlople byecuwr ar rxrn-ni rip,3wpplp
cells ONLY trllh rlM svmr raisurxllotv4zM1mrrkrvaeru.tau rnn srrhmit wrr furiq_ 10a, For All Wdlkc Submit-this font viithin 30 day5 of completion of vtrll
6a WCOID#9CeT-12-25
'abindour6cnt to the following;
DivisicinofWaterResources,Information"Pin essengUnit,
(ti)
1617 mail,Seiyice Ccdteri R ileij li,KC 27699-1617
66.Total.ttell depth: 25
10h.For Tnleolon Wills: ht addition to seudigg the foint to the addiess In IOa
Gc.Elornholc diatucter:2 (in.) aiboiv.also submit one colt'of this;foinr withitt 30 days of"cotuptetion of tuell
*iudomnetn to the follatt•ing:
�d.lVatcr leer l,bclon" curl surface: 15 (ft,) Division:of Water Resources,Underground Injection Control Pr6gtami
1634 Mail Seater Cc'tc,Ralcit ly KC 276'1')-1636
6c:Outer caan lea if Imown): (lL.") Inc.Fnr Water Srmnly th Itrtectioo W0,1ts: In addition-to sending the fort to
fi ( _the addiess(es).abq�,e.also submitlotie copy of this.fotm witbid 30 dajs of
compietiou of-well abandmmrant to tire-witnty health dcpatimerd of the pointy
Gf.Inner eosin;ftnbing tcn)Kh(if[matrn):10 (fL)
whcrc alrrndoncd,
i
ft Screen lengtlt(if k6ottn):15 A)
Form M-10 Monti Carotim Dcpprtrucm of Environment aryl Narutal Reson:res-D1%1SfgR of lVatcrRcs mas Revised Augusa 200