Forsyth_Well Abandonment_20240311

WELL ABANDONMENT RECORD en Far.InlCmat.LascONLY;
This.fonri rag lie useii foe sinSte ae tnullip[e`is€ils � j
1i
1.WOLCuutracdoe><nroripatiOnt \� WELL ABANDONMENT DETA1L,Ra
Rich Lemire 7p.Number of it-dis king alaandbnW: 1
Will' au m6i rNaus:(or.ivap4ilAdkvt S4.aWrldinguutl6uld5llacrpruticayq) Far rWffip'ly 111je'uar or mn-imiq supper, kfei1s' ONLY wtab Nay saare
atiruYfrarco(e>'�'raa�rinnruaraf,she([jursaifvaiaf,rNrsfriran,
2593A I
7b.Anprnximstta viiluuac of 1�at�ti=aitae:tini®t;iti u•cll(vj�oNE (p;�-)
NCWe1lContasctur�-itiT�lioiiNnuitcr - i . . - ,. -
SAEDACCO
FOR 1VATE}R.SUPPLY 11�KL[.S ONLY-,
Cunapatn+Iramc 7c tvW of-do infcctianq ys'eds.CHLORINE
2;-$V1(ConstiuctiuuPermit@:WSW-1,--,- --- -- _ - _
fld irll trli'Pltav64;Ia ell Earutitti(l.a!Ca partly,Sru(a;d'arl�ince,Iirjaifiura,ch:1 fJRlaeawra. - 7d.rintount of d131nfaxcsuit usrvl1:5 oz
3.1Vo usiO4yy0rlu}.
1Vater-Supply lYell: 7c.Scaling r o itcrl:tLs used 4cl!ect;all ifint apply}:
❑A itttttsril CJhAitnic palfAtifiitr: M T wt ccwp nl.Groatt. M-scntonl(c.Chips 00cllcts•.
gt�cothcrmal(Hc ttinr�f Caolino Supply} wl2csicterrtittl�Vatcr Supply'(sinr�lG) ❑Soud Ceillelu Cmut O'I)ry CLy
[ylndustrial/Gomnur>ial 179cesidcnda t.%Vatcr Supply(slraeal) p Cquct,to Grout brilltltUiiigs
❑lrri tiau .17:Specialty.Grotel 17:1di-avel
Non-Water Supply Fyc4fa - - - 13:Bentouite 5iun 0 6&r 4explain under 79).
[7Monhodng ElRecoety .
Injccti9n;lYc1I: X For,each relater€id selected ali6ve,provide antount-of nttttcsials treed:
�Aq'itifcrldgcfiar a l7Croutidr}aleilderited'uitlon Neat Ceara.•1833lb ,Wtr•100ga1_ Sand Cem.•lb ,Wtr•gal.
liAttuifei Stowe and Re cbN;eii l7;attliitifwll ttics
nAiti,lee nest pS(duliniaterDiiiinage
DExprtinteulal-RvItuola4•v t]Sultsialerkr:CoaNml 7� 1*eus%dc a brii r d�rcriptiun nr;t6c altaadnnmcrit prit ialum:
0G.ntflemral(Closed:Loop) Mracer
�1Geothcmtal(Ht4iu CaaliodtRetum) 1�Gthcr4exp15in llndef 7$1 GROUTED BOTTOM OF WELL FROM 31' TO 14'THEN INSTALLED 57
STONE FROM 14' TO 4' AND PUT CEMENT CAP FROM 4' TO 3' AND
d.`R�fCSF'CIC(S}.tthhntlpnCc; 2-26-2024 REMOVE CASING AND INSTALLED DIRT FROM 3' TO SURFACE.THIS WAS
Sa.Well lncattiolu A SEEP WELL. 'i- L <
Private.Residence MAN �O�AY
Frrtilp?y�vtrarNairue Faoiltty�ION cirtippkible5- S;Cet�ltllatiair:
18 West Clemmonsville Rd. Winston Salem 27127 � _
Sin_clIIiui .,iili�vtWc11coIIIi;;loroft4ctlthrn:r Plri�sical rldalress.City:;raid Zip _
FORSYTH fiy•signiny rhos jgrnt, !hernhy cer'fi}*y dffll fire rreli(s) was(ira:re)ahundenerl i;t
Couull Nr.ql Id nliE`c>gi bitNo.(PIN) aceunl nr c Ir l 11.�.L:tG�JlC.()Iflfl Or 2C-.O200 IGe17 Caiirsli ucUuri Sfatrikara�x
and dral rl ixap}•oJffris rccvrd lyres berat;um>iu'crl to fhau•cll mrraer.-.
Sb«A.atltu t6and Fora iitrrvAa„in dcgtrccslntitiutcs/scennds of dtciiu,t I cic>;m6:
(Itn'ctl jrwtd,oaac titllotig is a7rfticiearl>. 9.Site diatgrat dot'adciitlan;rl n'cll''detafls:
YOU ivay'use 11ic.bacl,'+of Utis page lu'pt&ida additional Well site.details or mill
A' N �aliawdenntent datails. 1'oti Wray also autach aclrlitiatit:tl pabcs if tiec�saty. ' ..
COVt TRltf` ON t1E:TAIIL.4 OF WELI.ISF SLING ABANDONS® -SL1Bhi117' .,A1VST1tTiIQ'T mmI '
Awtb u�-ll auaiviractidu rairrrrdls) For naiahiple i;byagiu 6u tmlmluter 3iayph-
urlbiOAtLYntPXrluSvmaci7tatlnxllvalloSnarehvrraa4aP,jvraemavraMltuin�ji'nrr. IlOai,BorAll Wells: Submit this 11arm:siithin'30.dlvs of cornpiction of well
{a;1Vc0o Qj .WSw-i atiandontucni to the tallovvinG:
Division-of Water Rmi ur>viy,dnfarmatiitti P tiem--esingEnit,
1G17 htiiil Sci�ice feu@ci;Itailei*Ii,IVC 276§9-1617
ab:'Eatal wetl depth: 31. (fr;) g '
CUb;Idrir in lectian W Wditioti to srndiug the fOmr ro the address In l6a
fie.Botyctiole dhtritcter:24 (iii:) abom atsri subpol oite tboy of obis rut ivilltiii 3b'doys of com&4iou of Well
:ibaindounteit!eo thc.falldwin>; i .
fi4l.`iVatcetcvcl,bclocsgosantlsttrruce� 28 Dhiatettpf%aerResourus!Utdergroun aMIL-citonCriirttitlPrdgratu,
rt531i llfiail SciicC Ccreter,Ralcigh,1�C23699-lG36
6e.Autccea�inMletegtti.4ilmnna): 31 (ft} t(Ie me` ccr i ryrl�� .inter�,ti�n 'gt6s: Ito�c@ciitian I©scndiat3 Ate fame to
the addresses) abate also Subunit bue-copy of this.folul Mthin ate days of
c0nip. au of yell ahaudaair»ent(0 the Molly Irsaltis depustntetd of lbe eountt*
Gf..lniiur casin/tuUFn Ccnl,Kl,(if IMovYn)a N/A Ow 'v'Wre abandotacd,
6g,Sereen Irvtt(,Hlt(if liniir'4):N/A
j
Fvmi OW-10 Nonli uallon Depanm ept of Emirmuma t aid Numi ficsoumes-Divislou of Nhtcr ltcSotun:s Etcviscd Augrnt.ZW
I