Forsyth_Well Abandonment_20220923

WELL ABANDONMENT RECORD For Intemal Use ONLY:
1,Well Contractor Information: WELL ABANDONMENT DETAILS
Virgil Wilson 7a.For Geoprobe/DPT 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
4473 wells abandoned:
NC Well Contractor Certification Number F.�r.-.
cam;%x 7 °'� "`�� 7b.Approximate volume of water remaining in well(s): 7'26 (gal.)
Parratt-Wolff S p D 2U2� FOR WATER SUPPLY WELLS ONLY:
T Company Name
' 7c.Type of disinfectant used:
2.Well Construction Permit#: +
List all applicable well construction permits(i.e.111C,County,State,Variance,etc.)ifknown
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 s Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
PlMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 7.26 Gallons
❑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) ❑Other(explain under 7g) 4" Stick up with 3 bollards. Dispose materials off site.
4.Date well(s)abandoned: 8-17-22
5a.Well location:
Waste Management of Carolinas
Facility/Owner Name Facility ID#(ifapplicable) 8.Cer tion:
3303 N Glenn Avenue, Winston-Salem VA4L ,t'. I �Z
Physical Address,City,and Zip Signature of Ccr ell Contractor or Well Owner Date
Forsyth 6836-57-1919
By signing this form. 1 hereby certify that the tvell(s) was (were) abandoned to
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has beer[provided to the well owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hit/long is sufficient) 9.Site diagram or additional well details:
36.127762 N -80.234935 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 SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifarailable. For andtiple ityection or non-water supply wells
ONLY with the some constructionabondonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-01 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 45.4 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:
2 (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: None (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.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
611 Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016