Forsyth_Well Abandonment_20241022

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Zontractdr Inf emotion: W
ELL ABANDONMENT DETAILS
U � 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well ContractorName(or well ownerpersonaily abandoning well on hislimi-property) well construction/depth,only I GW-30 is ceded. Indicate TOTAL NUMBER of
r��(, 8 n
wells abandoned:
NC Well Co tractor Ccnifica'on Number 7b.Approximate volume ofwater remain ling in well(s):_(gal-)
•� 1, C• FOR WATER SUPPLY WELLS ONLY:
Company Name V
H—1 lJ L�\D�L%
7c Type of disinfectant used:
2.Well Construction Permit#:
List all applicable t%vJ1 construction permits r e.UIC.County,State,Variance,eta)ifknoim O�
- 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 orPellets
❑Geothermal(Heating/Cooling Supply) tesidential Water Supply(single) and Cement Grout re ti._,1:�' ,;' ;z O,pry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout A❑Drill Cuttings
❑irri ation ❑Specialty Grout OCT 2 ,% ZOZ4❑Gravel
Non-Water Supply Well:
❑Bemonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f_For each material sele�fed nbove;v rovi/de amount of .materials used:
❑Aquifer Recharge ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑SubsidcnceControl
❑Geothermal(Closed Loop) []Tracer7g.Provide a brief description of the abandonment procedure:
ll-
OGemhetvial(Ileatin�Cooling Return) ❑Other(explain under 7g) �' ���n�b�� i ml�\>t✓ kk P m ml P s y
4.Date wdl(sj abandoned: y' f t• `
Sip cam:
5a.Well location "ck It
Facility/Owner Name Facility lDN(if applicable). B.Ce cation:.' q 1 •C` �� 5v t
Physical Ad n,and Trp `�'• —t�i 1 l Signature ofCenified Well Contractor or\Veil Owner Date
By signing this Jbim, 1 hereby certify than the ivelf(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance ivith 15d NCAC 02C_0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude indegrees/minutes/seconds or and that a copy of this record has been provided to the ivell•oivner.
decimal degrees:
(if well field Vl one Iaong sufficient)
is sucient) !
9.Site diagram or additional well details
5 6 r`LA 3 C(St N 0 . �$5 U b 5 You may use the back of this page to provide additional went site details or well
M abandonment details. You may also attach additional pages if neces§ary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attachutellconstrucaonrerord(.v)ifarailable.Formultiple injection ornon-natersupph•trrl/.c
ONLY xith thesame construction/abandotmrent,you can submit oneform.
10a. For All Wells: Submit this fours within 30 days of completion,of well
6a.Well iD#: abandonment to the following:
�j Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
it 10b.For iniection Wells: in addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above,also submit one copy of this form within 30 days of completion.of.well
1, abandonment to the following:
6d.Water level below ground surface: 4�v (ft:) Division;if Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 276991636
6e.Outer casing length(if known): 10c.For Water my&Injection Wlls: lu additio toselgthe frrm to the_ ain
address(es)above,also submit one copy of this fort within 30 days of completion
of well'abatidonment to the county health department of the,county where
6L Inner casing/tubing iength(if known): (fi) abandoned
u
6g.Screen length(iiknowti):' (ft.) .,.
Form OW-30 North Carolina Department of Environmental Quality-Division of WaterResources j Revised 2-22-20I6