Forsyth_Well Abandonment_20240429

WELL ABANDONMENT RECORD For Internal Use ONLY: j
I.,nil Contracto nrormation• WELL ABANDONMENT DETAILS
Ut c- 12 p a p-0° — 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well ContractorName(or well ownerpersonally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
RCX�3 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remainii g in well(s): (gal.)
�i L. �{Z►1 l) 4L=9 PC.. FOR WATER SUPPLY WELLS ONLY::
Company Namc
7c.Type of disinfectant used:�
2.Well Construction Permit#: —7
List all applicable null construction permits r e.UIC,County,State.Variance,etc)f tnoirn
- 7d.Amount of disinfectant used:
3.Well use(check well use): _
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) )tResidential Water Supply(single) g Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑kri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GmundwaterRemediation �„f `' ^
G T
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Draivage
❑Experimental Technology ❑Subsidence Control f(
7g.Provide a brier description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geotherwal eating Coolin Kelton ❑Other ex lain trader 7 v c.Z p bGJN���t t� t 1 � •` ' '~" " `�r,?,
4.Date well(s)abandoned: - � ° �.Q��V,e t �,- co(u4. C n�•'J)
+l i ��
Sa.Well location:
T►?'l;if\eG LUt G -1. .-f L't71 CV\
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Facility/Owner Name 41 Facility IDN(ifapplicable) 8.Cer
tification:
c' q-aq It�`e✓
Physical Address,City,and Zip _ L, 0.�p Y Signature ofCertified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with l5A NCAC 02C.0100 or,2C,0200 Well Construction Standarzls
and that a copy of this record has been provided to the well ortmer.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 9.Site diagram or additional well details:
W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well cotnrraction record(i)ijarailable.Formultiple injection ornan-natersupplr wells
ONLYadth ilia same constrtctionlabandonnrew,you can submit oneform.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID##• abandonment to the following:
U 5/ Division of Water Resources,Information Processing Unit,
6b.Total well depth- / (ft.) . 1617 Mail Service Center,Raleigh,NC 27699-1617
at I 10b.For Inieetion Wells: In addition to sending the form to the address in 10a
b6c.Borehole diameter- (in.) above,also submit orle copy of this form within 30 days of completion of well
a
abandonment to the following:
6d.Wager level below ground surface: (ft) Division pf Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft) 10c.For Water Suoaly&Inieetion Wells: In addition to sending the fora[to the
address(es)above,also submit one copy of this form within 30 days of completion
.� of well abandonment to the county health department of:the"county where
6f.Inner casing/tubing length(if Mown): ({t,) abandoned
6g.Screen length(irknown): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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