Forsyth_Well Abandonment_20240624

WELL ABANDONMENT RECORD For Internal Use ONLY:
I.Well Contractor Information: WELL ABANDONMENT DETAILS
Jamie Neugent —
7a.For
lls having the same
Well Connector Name(or well owner personally abandoning well on his/her property) well construction/depth,my 1 GW 130 is needed. IndicatPT or Closed-Loo Geothermal e TOTAL NUMBER of
2677-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
AquaDrill Inc. r FOR WATER SUPPLY WELLS OPILY!
Company Name
/' t , 7c.Type of disinfectant used:�Z.-,-1 7s JZ
2.Well Construction Permit#:J`-��c -W y/� ,
List all applicable well construction permits(i.a.UIC County,State,Variance,eta)i—flmolm 3.Well use(check well use): A
7d.Amount of disinfectant used:-_,/r1 J 1
—
Water Supply Well: 7e.Sealing materials used(check all that a
❑Agriculturdl
❑tv icipallPu 0 Beblic ❑Neat Cement Grout Hentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) estdt•,ntial Water Supply(single) ❑SS d Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) of Concrete Grout ❑Drill Cuttings
01trigation ❑Specialty Grout Cl Gravel
Note-water Supply Well:
Bentonitc 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..,
❑Aquifer Storage and Recovery ❑Salinity,Barrier --
❑Aquifer Test ❑Stomrwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Ter 7g.Provide a brief description of the abandonment procedure:
❑Geotherma!(HeatingtCooling Return) ❑Other(ex lain under 7g)
4.Date well(s)abandoned:
52.Well location:
.r
�aC•�tC.e?L'.�
Facility/Owner Name FacilityMOO d Ir arra,�Qr� '•��xs'- U+
{' applicable) S.Certification: �
Ptiysial Address,City,and Zip Signature of Certified Well Contrwor or lWe-I Owner
County Parcel idea fication No.(PIN) BY signing this faun,1 hereby certify that the well(s) was(were) abandoned in
accordance with 15A NCAC 02C.0100 or 2C.0200 Well COnstniction Standards
Sb.Latitude and longitude and that a copy of this record has bet n provided to the well owner.
ttgi in degrees/minutes/seeonds or decimal degrees:
(itwcu t5eta,one lattlong is sufficient)
9.Site diagram or additional well details::✓f1��g' N -fO i 7`d ���� 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.
CONSTRIiCTION DETAILS OF WELLS)BEING ABANDONED
Attach wet/cunstnUenon records)i(amilable.Formtdtiple injection or non-water supply wells
INSTRUCTIONS
ONLY with the same consiructionlabandanment,you can submit ane form.
10a. For All Wells: Submit this :orn within 30 days of completion of we1.1
6a.Well ID#: abandonment to the following:
Division of Water Resources,laformation Processing Unit,
66.Total well depth: (f!) 1617 Mail Service Ceater,Raleigh,NC 27699-1617
r 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter. pf (In,) above,also submit one copy of this form within 30 days of completion of well
9 abandonment to the following:
6d.Water level below ground surface: �" (@,) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Ceater,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (n,) 10c.For Water Supply&Infection Wells. In addition to sending the form 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 known): 1 (ft) abandoned.
6g.Screen length(if known): 14-1/if (B,)
Form GW-30 North Carolina Oenartmew of Anvimovv i n„s i;,,