Forsyth_Well Abandonment_20240624 (3)

iWELL ENT RECORD For Internal Use ONLY:
i.Well Contractor Information: WELL ABANDONMENT DETAILS
Jamie Neugent —
7a.For
Well Contractor Neme(Orwell owner personally abandoningwell on his/her property) well onGeop beefDPT or Closed-Loop Geothermal Wells having the same
p perty) pth,only 1 GW-:10;is needed, Indicate TOTAL NUMBER of
2677-A wells abandoned: _
NC Wei Contractor Certification Number 7b.Approximate volume of water retraining in well(s):—�Z
AquaDrill Inc. _ -----� )
' FOR WATER SUPPLY WELLS ONLY:
Company Name
lc.Type of disinfectant used: °
2.Well Construction Permit ax: �'-i i e �i�'L/11 7 a�� —
List all applicable well construction penmts(i.e.UIC.Count};State,Yartance,eta)iflaeanvn
7d.Amount of disinfectant used:_LP a Z r��
3.Well use(check well use): _
Water Supply Well: 7e.Sealing materials used(check all that a 1
[]Agricultural ❑
Agricultural PD Y):
Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) CBl(esidential Water Supply(single) ❑Sand Cement Grout
❑IndustriaUCommercial ❑Dry Clay
❑Residential Water Supply(shared) Cg Concrete Grout ❑Drill Cuttings
❑Irri ation
Non-Water Supply Well: ❑Specialty Grout ❑Gravel
❑Monitoring ❑Recovery ❑Bentonite Slurry ❑Other(explain under 7g)
Injection Well: 7E For each material selected above,provide amount of materials used;
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure: t
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under 7g) �emwBG1 /qp, fltlf/{ii d G/q>�
4.Date we0(s)abandoned:_�6 0�/ Z�� C /Of6 afed Cttbe4,f cfrUGI/eol, !t7 -fAr00/►7
Capped w;�j( Srau t :Fr/let ;n w e�1, Glfr 1
5a.Well IocaHon: � —
�6 67 —
Facility/OwmrNam Facility lD#(ifapplicablc) 8.Certification:
IS-'10 'yew Avt
Physical Address,City,and Zip j=ar sr. �/
turc of Certified Wcll Contractor or Wall Owaa par
>ch
County—� Parcel Identification No.(PiN} BY'signing this form, I hereby certify that the well(s)was(were)abandoned in
accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Conslnaetion Standards
5b.Latitude and lougitude in degreesiminutes/seconds or decimal d and that a copy of this record has heen,arovided to the well owner.
g fa sufficient)
((f-11 field,one IwAon �e�'
9.Site diagram or additional well det;rils:
N 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(S1 BEING ABANDONED
Atiacitwelicunstructmnrecurd(s)ifavadable.Formullipleinjectianarnan-warersupplywel/s SUBMITTALINSTRUCTION5
ONLY with the same cnnstruelionlabandonment,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 Resource Information Processing Unit,
66.Total well depth: 3 G (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
Zo 10b.For Iniection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: (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: Z 3 (It) Division of Water Resources,Undkrground Injection Control Program,
A 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): /a (D,) 10c.For Water Supply&injection W:Ilil: 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 :wealth department of the county where
6E Inner casingitubing length(if known): N�_(D,) abandoned.
6g.Screen length(if(mown): A (ft.)
Form GW-30 North Carolina Oenartment nFFoafrn .,ci ti—i;,.,-n;.,;..:,.-