Forsyth_Well Abandonment_20240529 (4)

WELL ABANDONMENT RECORD ForhrtcrtwlUeeUNLY:
1.Well Contractor information: WELL ABANDONMENT DETAILS
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01 �)� /yJ(9?��7� 7a.For Geoprobe/DPT or Closed-I.00p Geothermal Wells having the same
W omrar for Name(or well owner personally abandoning well on hitcher propeny) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC\yell Contrtctre Cenifreation Number 7b.Approximate volume or water remaining in well(s): (gal.)
M 'W a4zl FOR WATER SUPPIA*WELLS ON IN:
Company Natm 7c.Type of disinfectant used:
2.Well Construction Permit 4:
Lire all cgtplicable well rvm.sbvrtinn/ta•rntits ti.c.U IC.County.Stale. Variance.etc.)ifknoa•tr
7d.Amount of disinfectant used: r
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural CM opal Public ❑Neat Cement Gaut ❑Bentonite Chips or�l�i�ts
❑Geothermal(Heating Cooling Supply) esidenrial Water Supply(single) ❑ Cement Grout ❑Dry Clay y
❑Industrial/Comincrcial CRcsidenrial Water Supply(shared) Cnttercte Grout ❑Drill C uttinl�,"
❑bri tion ❑Specialty Grout ❑Gravel
Non-Water Supply N'cll: ❑ Bentonite Slurry ❑Other(explain under 7g)
U Monitoring L Recovery
Injection Well: X For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwatut Remediation
GAquifer Storage and Recovery L'Salinity Barrier
F1AquitbrTest I!Slormwatcr Dminage
❑Experimental Technology ❑Subsidence Control
7g.Provide a, ef descript' or the abandonment pros ore:
❑Geothermal(Closed Loop) ❑Tracer
❑Gcothermul(Ileatin ,Coolin Return) ❑Other(explain under 7
4.Date well(s)abandoned:
5a.Well location:
/ter-
Faeility Uwnc amG c Facility 10#(ifappli able) S.Certification-
Physical
AddreCC.City.and Zip i _.___.___
P Si o enifted Woll Contractor Wrll Owner D e
By s(gning this forn), I heirbr ceni i•that the mWI(s) pure(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 AVAC 02C.0100 or 2C.02011 Well Con•stniction Slandardf
and that a calm o f this rev oni has been provided to the well owner.
Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(tf well field,one tat long is sufficient) 9.Site diagram or additional well details:
l(!, ✓`/�Z O 416
/L N � fQr t 2-:F&3 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 ifnecessary•.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Anar/rit ell corntructionrecard/sti/m•ailahle. For atuhipleiniectionor non-hater utpph Neils
ONLY vitb the same cat..%tp w+bat tndonmrat,rott snot submit one 16nn.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: Oft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Well&: In addition to sending the form to the address in I0a
6c.Borehole diameter:� Qn.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 00 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniecfion Wells: In addition to sending the form to the
addresses)above,also submit one copy of this torn within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner caslug/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): Oft.)
Form tIW-311 North Carolina Department of Iim iruniviontal Quality-Division of Water Resources Revised 2-22-201 a