Forsyth_Well Abandonment_20230602

`1VEL,L,ABANDONMENT RECORD For Internal Use ONLY:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
K. Brandon Moore 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 1 GW 30�is needed. Indicate TOTAL NUMBER of
2957-A wells abandoned:
7b.Approximate volume of water remaining in wells. Unknown
NC Well Contractor Certification Number PP g ()' (gal•)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
2.Well Construction Permit#:
394997 7c.Type of disinfectant used: yp
List all applicable well consiruclion permtis(i.e.UIC,County,State,Variance,etc.)ifknown 7 oz.
_ 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 or Pellets
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 6 Concrete Grout >;_ r 4.- r .• Q'�6 cuttings
❑Irrigation• El Specialty Grout ` 4vr " s Q vb]
Non-Water Supply Well: ❑ Bentonite Slurry J Ul N (l 2 2O ZQ Other(explain under 7g)
❑Monitoring ❑Recovery L J
Injection Well: 7f.For each material selegted ahove erovide irpopnt of materials used:
Aquifer Recharge ❑GroundwaterRemediation lft°''"'"e5.ttin'i r��•'�i" 3 'r
Carr, ;: - 4 cubic yards
❑ Concrete mix �
[]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) ❑0ther(explain under 7g) Poured concrete directly into well casing
and filled to within 3 feet of surface where
a.Date well(s)abandoned: 5/30/23 a concrete plug was installed on top.
5a.Well location:
Jackie Cheatdom N/A
Facility/Owner Name Facility lD#(if applicable) 8.Certification:
677 Motor Rd. vR2%57 5/30/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Winston-Salem, NC 27105 6837-38-0955
By signing this form, I hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 01C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude indegrees/minutes/seconds or decimal degrees: and that a copy o/7his record has been provided to the well owner.
(ifwell field,one lat(long is sufficient) 9.Site diagram or additional well details:
36.158709 N 80.242984 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
Allach well cominiction records)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constnictionlabandonmeni,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 41 (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: 20 (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: 34 (ft-) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unknown (ft.) 10c.For Water Supply&Iniectionl 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): Unknown (ft.) abandoned.
6g.Screen length(if known): Unknown (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016