Forsyth_Well Abandonment_20240306 (5)

NVELL ABANDONMENT RECORD For irkmaltlscONLY: i
Thii form erns be used for single of niultiple*11s
1,Well Contractor Information: WELL ABANDONMENT DETAMq i
John Eisenman IL Numbcr of wells heing ahandenci li
%TpIrCormciorNane 4raClloii'nu. rsonall .tbamfordn;NuffonItkIlter ra n for raldUpk rrlft[YraJl OY ,fdUn 4W irp'pfy- wells' 'ONLY wrdi Me .sautR
oorfsrrrrcrla�.obmrdrrilw�ar6 yr�n ra>r st!viiir GvrctJFirnr.
4439A
r 711.Anitrox6nitte Volume of*ater rYmaining inn(vell(rp
WC'Kcll Cbnlydctori7CHM6801i Number
SAEDACCO FOR WATER.SUPPiX WELLS ONLY. !, '�s L—t
Conrpan}Name 7c.Typc of disinfectant rued:na (i�AN 114T024
2:Nell Construction Permit M:,_'---------_ -------- -- _ ---_--_ - -
Lt4dl appfliv8le treflpermitr(ia!GwrN'S(atc,Yariarry e,fiy4cfiar;,tic}ff(town `�rt7ii�iEit P w&d
7d,ltnottnt of dlsinfMAut'used:
3.Nell ttsr(chedcit•cll usC): -
Water.Supply°Well: 7G Scaling matcaistJs:used(chcci;all tit tt apply): .
17rtgriculhtral phltinicipallPttblic 13 Ncat Ccment.Gmut Q Hctxoniti Chips sir Pcllcts.
130mthcrmil(HcatinglCooling Supply) Qkcsidcntial 1Vatcr Stipp$'(single) EI Sgnd-.Cente*Grout ❑Dry Chiy
❑hultisirialfCommcrcial ❑ltcsidcuti,'rlWater Suppy(rt>rrcci) E3 Concrete Grout O Drill Ckafingi
❑hri [ion - ❑Speci41}'Gcuut ❑Grsrel
Nan-WaterSupply 1Vcll: - .O BentouizeSluny ®Oiher(esplamptider7g)
i9MmdtorLne,. i7Recovety..
Iajcetian Nvglt:. . 7f.For each ttiltcrla[sctccteil abagr;prb�ide riuiott®t df•rititcrials nyed:
EIAgnifcrRecharge, Mrouiainul' Rem ediitlion, {
I]Agiri[er Storage otxi Recoi e*, t]Salinity Barrier
OAguifei Test L1Stonmr:ttet Drainagd.
Bentonite.:801b ,Wtr:gal. :
EIF-VerinieulalT&heotogy i7SubgidenceCoottul. '7g.Provideabrief-dcscriptianofthc.abandonment rroc0un:
®Geothermal(Closed Loopy Tracer
pour pellets doeh well from surface operiodically checking
®Geothermal(Heitung Coolie Retum) 170thertex laini under 7g)
depth, with'tape measure to ensure they are reaching bottom,
d.Datcwell(s).abandonetl: 2-6-24 continue this process to surface
Sa.Well location:
Omnisource
Facilityi(hvncr NMC Fxilft IDN(Inapplicable) $•CctllRcntioit:
--
1926 W Mountain St., Kernersville, NC 27284 2/22/2024�-
Physical'Addmss.City,arui Zip S Iltti �! + ' —r._-- s r'.ibr Dale
Forsyth Bys!Sizing 1hr_{ r:rifi'•rhat the irell(s)mwv 6oWw)abandoned in
Ctiourstl' Parcel l_d2ofCe6kbit No.(PINj nccvrdahcetnihiMANCAC.02C.0100.ur2C.0200 Well'6iisliuclion'Etrinekarls
mzddtid a copyofibis record hasbefir provided tonne well owner:
Sir:I atittidc and longitude in degreeslmriltuteslscconds orilecimai degmcF- I
(Wii•ell rok orb:Llopjlg'it ndnekti) 9 Site dlagtam or addidamal well details
You tua}use ilie•ba&pf mis.p.ge tu,owvide additional well site delails.or ccell
N .a6audohu1ent details..Yau tuay als6ai(ach additional pages if necessary-
CONSTRiII"1•ION DETAILS OV WCLLlS)BEING ABANDONED Stint TTA1,tNRTiRLTCTfONS
i
:Iflath.114 cu&%, rctrart 2Eurd(s)'if availrarila! ran rrulriplr rifreeiwe'or Pon- arir sip fy
units ONLY 11-k JIM snmg iau coo sirbmn corn furnr. 1pa.For All Wells: Submit chi Cntnr aiithin 30 days of completion of it-c
6a WCII ID#eCPT-12-50 abandaamcat to the follai"Fig: ;
DiAsion of WaterResuarce!4Information-ProetwWng Unit,
l 50. } I617 li A Seftice Center;Palci;,li,NC 27699-I617
6b.Total:well do ith: fr.
L .
100.Forth IWIon Wells: In addition to sending the form to the address in 10a
above.Also submit,one.copy of tbiS form uithiif 30 days of completion of%yell
6c,Borehole diameter.2 (1u.} abiuidomrteut to the rallowfilg:
6d.`Voter lcccl.bctea'gr onind surface.30 (f�,) Division of Water Resouries,Underground injccgou Control Prtigraru,
1636 Mail$entice Cciuter,Raleigh,XC 27699-1636
loc.bar\Yates Strrinh•&L tian riee Wells: ltr addition to sending the form to
6c.Outercasinglength(ifimpnn): (f�) the,address(es) above. also subtuif oite:copy of this limn within 30"d#s of
comptction-of well abandonment to t6elcoanty health depmnnteit of the county
6f,Inner easing/tubing leniph(if linown):35 (fE)
lrlicrc abandoncd,
6f.Slrrcn length(if known):1-9 00
I
Foim GAI-10 North Carotirn Depaunxm ofEmironmem and Natural Resomees—Division of .1terk.I.Mes Revised Ann"20 B
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