Forsyth_Well Abandonment_20240610

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
7a.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
Y5,e Z_ ( wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Morgan well & Pump, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name G r l ,�`�.`
39 -7Z Z 1 i 7c.Type of disinfectant used: Iwo
2.Well Construction Permit#: `�
List all applicable well construction permits rL e.UIC,County,State,Variance,etc.)if known 2
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Xesidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) Concrete Grout ❑Drill Cuttings
OIrri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation �.- . . r r"Z
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage JU N ( & 4
❑Experimental Technology ❑Subsidence Control 7 ,provide a brief descri
❑Geothermal(Closed Loop) ❑Tracer g p"on of the aUandonmecttl,pro # ,�L j,t*
❑Geothermal(Heating/Cooling Return) ❑Other lain under 7 �e /C ` i �� �C.V 3 Fcef—
S Low gc�k , c d t-7 o z
4.Date well(s)abandoned: ,y-Qe tAJ,
5a.Well location: �Vy\� Q ' I U n��
L.
CGIC h om� U s t tt V c/1i
Facility/Owner Name Facility ID#(if applicable) 8.Certification'
EwellPhysical Address,City,and Zipwner Date
By signing this form, 1 hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if wellfield,one lat/long is sufficient) 9.Site diagram or additional well details:
3(/o'd('ft 6 Sa 1 N S b-Z-s G 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 SUBMITT,U,INSTRUCTIONS
Attach well construction records)ifavailable. For multiple injection or non-water supply wells
ONLY with the some construction/abandonment,you can submit one form.
10a. 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: M.) 1617 Mail Service Center,Raleigh,NC 27699-1617
(� 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 —i (in,) 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: 3 5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): A— (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 3,0::days of completion
of well abandonment to the county health department,of.the county where
6f.Inner casing/tubing _ ) abandoned.
length(if known):Ayt- (ft
6g.Screen length(if known): /V/ R—
Revised 2-22-2016 .