Forsyth_Well Abandonment_20220603

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David Hardy 7a.For GeoprobeiDPT 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 I GW-30 is needed. Indicate TOTAL NUMBER of
2906-A wells abandoned:
NC well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): _(gal.)
Aqua Drill, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
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7c.Type of disinfectant used: ff ff1 `�/�✓ !�`�C
2.Well Construction Permit#`? Vl.� A' 7
List all applicable well construction)1erfitits i.e.UIC,County.State,Variance,etc.)ijknowrt
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check ail that apply):
❑Agricultural ❑M�unicipa/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) dl-esidential Water Supply(single) ❑,�Srrand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ["Concrete Grout ❑Drill Cuttings
❑lrri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 11AIJ,
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer / (/ _
❑Geothermal(Heating/Cooling Return) 00ther(explain under 7g) �`M Nd ° hy',w aw'ro �A)4,0
4.Date well(s)abandoned:
5a.Well location: �+ J
Cl eyrV
Facility/Owner Name Facility ID#(if applicable)
'lei -x2
Physical Address,City,and Zip si tore of Certified Well C ctor orWell Owner Date
By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and lone tude in degrees/minutestseconds or decimal degrees:
(if well field,one latllong is sufficient) 9.Site diagram or additional well details:
N �� �� � You may use the back of this page to provide additional well site details or well
G✓ "2��0 `rf' W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)lfavailable.For multiple itliection or non-water supply wells
ONLY with the same 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:
"F:FVF
Division of Water Resources,Information Processing Unit,
6b.Total well depth: ({t) JUN 0 1617 Mail Service Center,Raleigh,NC 276994617
�2Q22
�f lOb.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4!�se"� (in.) � above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
4W PRQM UM i
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
L 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): rCT ({t•) 10c.For Water Supply&Injection 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): (ft•) abandoned.
6g.Screen length(if known): (fL)
s
Form GW-30 North Carolina Department of Environmental Quality-Division of WaterResourcesr Revised 2-22-2016

o3NaRrs FORSYTH COUNTY HEALTH DEPARTMENT
Division of Environmental Health �P ` i } "`I r9 " 11)V
x P.O. Box 686, Winston-Salem, NC 27102
336-703-3225
-S
File Number s �' ` t`{
Lot '?;f" Block 47 j-w
WELL ABANDONMENT RECORD -
5V
Contractor cat b �n , ' Registration No. tcy a!r°°;
6x' t
Well Location: (Show a sketch of the site at the right on this form)
i
Owner.
t
Site Address �, = a �., z; SITE DIAGRAM
Topography: draw, Q__qpeD hilltop, valley, flat
Use of Well sr0 Date I `` '175
Total Depth < Diameterw.`''
Casing Removed:
Feet Diameter
I
gS fi
4 #
Sealing Material:
I
Neat Cement Sand Cement
I
bags cement bags cement
gals water yds sand
gals water I
Other: +
Type materials C-410c.
Amount /I
Explain method of emplacement of material:
4,-.1
.at }t €�
do hereby certify that this well abandonment record is
true and`exact.
Signature—Contractor/Owner "Date'
Signature—'E:H.S. °F. 'Date- ✓; ss� x•:. •e.:.
COPIES:WHITE—HEALTH DEPT. / YELLOW—CONTRACTOR / PINK—HOMEOWNER Rev&Reset FCPS 1-22-2014