Forsyth_Well Abandonment_20231228

i '
WELL ABANDONMENT.RECORD For Intental Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
J. Michael Venable 7a.For GeoprobefDPT 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
N CW C-2079-A wells abandoned:
NC Won Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 180 (gal.) j
Venable Brothers Well Coast., Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
7c.Type of disinfectant used: YP
2.Well Construction Permit/I:
List all applicable well construction permits(i.e.WC,Comfy,State,Variance,etc.)If known
7d.Amount of disinfectant used: 6 oz
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) 0 Sand Cement Grout ®Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) U Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery r
Injection Well: 7f.For each material selected above,provide rite at^als used:
❑A uifer Recharge ❑Groundwater Remediation i y .b D
q g well mix-2 yards z L: P L.i '--
❑Aquifer Storage and Recovery 0 Salinity Barrier clean clay-1 yard DECp 2023
Aquifer Test ❑Stormwater Drainage 2
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the;abandellh BUhptt y n
❑Geothermal(Closed Loop) OTracer dewatered well; chlorinated; DWQ/304743
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g)
removed top 7 ft of tile; filled with well mix to form
4.Date well(s)abandoned: 8/3/23 plug; topped with clean clay
5a.Well location:
PATH CONST/CONCORD WP
Facility/Owner Name Facility lD (if applicable) 8.Certification:
1908 MARGARET ST., WINSTON SALEM, NC 27103
e / 8/3/23
a.
Physical Address,City,and Zip Si tare of Certified Well Contractor or Well Owner Date
Forsyth By signing this form, 1 hereby certify that the well(s) was(were)abandoned in
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 been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lamong is sufficient) 9.Site diagram or additional well'details:
36.075008 N -80.301066 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. i
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED_ SUBMITTAL INSTRUCTIONS !�
Attach well construction record(s)ifavailable.For multlpleinjection ornon-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 DM: abandonment to the following:
I
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 20 (ft.)
10b.For Infection Wells: In addition to sending the form to the address in 10a
tic.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: 9 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft) 10e.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit onelcopy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6£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
1

WELL ABANDONMENT RECORD For Internal Use ONLY:
1
//1.Well Contractor Information: --�;- WELL ABANDONMENT DETAILS
(7G iu e UA..n 4r. $n-t-n d 7a 5e a pi v 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 130 is needed. Indicate TOTAL NUMBER of
wells abandoned:
/4/// - a.0me-Owt�a- tdia
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): J°Q (gal.)
FOR WATER SUPPLY WELLS ONLY:
Company Name w 1&
J� 7c.Type of disinfectant used: `4/4 PA'► A vim i4fo Awl
2.Well Construction Permit#: t 1/ I
List all applicable well construction permits(i.e.UIC,County State. Variance,etc.)if 7d.Amount of disinfectant used:
3.Well use(check well use): ,a l�Q'-(/1
Water Supply Well: / 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mu icipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) &fesidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑IndustriallConunercial ❑Residential Water Supply(shared) oncrete Grout 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: _ ❑ Bentonite Slurry 1 ❑ Other(explain under 7g) _
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount ofaterials•usecl
p �E� l
❑Aquifer Recharge ❑Groundwater Remediation , 5 ®5 •__ DEC �.
❑Aquifer Storage and Recovery ❑Salinity Barrier D V C 6 ) •
❑Aquifer Test ❑Stormwater Drainage ,
w,+vrmaiieit irrr;t;,v„gv:
❑Experimental Technology ❑Subsidence Control n9 Una
7g.Provide a brief description of the abandonment proce�u�r°er '9O 3
OGeothermal(Closed Loop) OTracer �� � �
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ® d kvitet p,v,,b�0� # p t'tip ® „"�'
' "'v" -'--
,5 y..® 3 e�44 .e� �J p, .A?24.Date wells)abandoned: l2.($72 3 ®�d)‘ i r• ir)/1 A-t e fl Cv4 d,; Gyp PI L1-ii
5a.Well location: ilb /' 104j? yoeb I > 3-/f be jfil Sr);j 4
ve,., dA �U I e11-j,o 8.C. 3'i ''"(-pst C�a
Facility/Owner Name Facility ID#(if applicable)
cation:
��se 7 -�w;ck (�d. ei c _,.). _ • 12.-S a
Physical Address, u'City,and Zip Signat erti led Well'ontractor or Well Owner Date
/ or57/ 44 6?fl-G5 - 3 75-3 By signi thi form, I hereby certify that the well(s) was (were) abandoned in
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 been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/Iong is sufficient) 9.Site diagram or additional well details:
3b- 01 op (,2 g N 90. p 3 57 W You may use the back of this page to provide additional well site details or well
VV abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available.For multiple injection or non-water supply wells
ONLY with the sane 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:
i Division of Water Resources,Information Processing Unit,
6b.Total well depth: 37 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
106.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2.y (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: 25 (ft.) Division of Water Resources,Underground Injection Control Program,
2 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): . 37 (ft.) 10c.For Water Stfiply&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.
r
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

ate;*,R, FORSYTH COUNTY HEALTH DEPARTMENT
°`� �`� Division of Environmental Health
a� u � - P.O. Box 686, Winston-Salem, NC 27102 '
,.;y �'i'�� 336-703-3225
41 '^� ) I File Number Y0�tif2—
. Lot GO B Block ,c`3 ?O
WELL ABANDONMENT RECORD
Contractor fT�llPi4 e p-l#eir ' Registration No. ' iti/,�
Well Location: (Show a sketch of the site at the right on this form) Well /
Owner eV eh do- /o SGapt.v
Site Address 20 5'0 -1)c4''14/ek R I.. SITE DIAGRAM
Topography: draw, sloe hilltop, valley, flat
Use of Well Prs vas-4e, Date 17c- id i/J
Total Depth 37 ' Diameter 2,/o
Casing Removed:
Feet Diameter
5, s
Sealing Material: 457-
Neat Cement Sand Cement
bags cement bags cement i �®
1 J
0 -
gals water yds sand �'a 5 �--I� )
gals water , , I"
Other: _
Type material k,q/ z
Amount
Explain method of emplacement of material:
0- 12&k.°Lee r CA.C$WI$1. 04,-d cii"e44,-- , ) '111,9z,z-,- ,.., ,
_ ,,,,,I, A.„,,, ii, ,suFfPfn Ciel-re ,- 3 441,,,, - 7)14-Pw leie AD 111. ....................A.„
ro 147 d w f fr, 4Q,
do hereby certify that this well abandonment record is f
tru nd exact VA _
, — _� ��,
0 n
Signat S'ntra.,sr/Owner Date
/ Z)
Signatu e—E.H.S. to
COPIES:WHITE—HEALTH DEPT. / YELLOW—CONTRACTOR / PINK—HOMEOWNER ! Rev&Reset FCPS 1-22-2014

WELL ABANDONMENT RECORD For Internal Use ONLY:
f
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Pi°hole0(e.41.41, Si 'C IA Jo SC A-*) 7a.For Geoprobe/DPT or Closed-ILoop 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
wells abandoned:
Ni2 N -dI•i#t e r 1 Q�
NC ell Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 491 ?O (gal.)
'— FOR WATER SUPPLY WELLS ONLY: i _
Company Name a C%v M I t y pQ(�IRDt/le-
/� 7c.Type of disinfectant used: �
2.Well Construction Permit#: t A)e If
List all applicable well construction permits(i.e. UIC,County,State. Variance,etc.)if known q d2-
7d.Amount of disinfectant used:,
3.Well use(check well use): Ff Oma' y
614,`4
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ❑ Sa Cement Grout 0 Dry Clay
❑Industria1/Conmmercial ❑Residential Water Supply(shared) oncrete Grout ❑ Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other egpltui nder4g)
❑Monitoring -- -- ORecovery I _. - j '�e L 1/_Y�`�i —
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 3 l or d 5 DEC 2 8 2023
❑Aquifer Storage and Recovery ❑Salinity Barrier 111EDF7l2n Prot-
❑Aquifer Test ❑Stormwater Drainage n.. --'' '-B9 tint
❑Experimental Technology El Subsidence Control
' 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer � 1 p
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g) C� tQ t- Over 1 e JV F+@,i Aff ) pi M tie) O ti4 0^'C�Y'
Atha) 3 oy. e e-;v� APP791e-
4. >
4.Date well(s)abandoned: /2 f /73 6, y)v 3/ d ewkt 4 II D_,1 4O &i i A�_ p� / _�
5a.Well location: 8)OJT d 3/ i 6 t/" �'y'G `iW
6reh d4 Te s a en.p ~ O n ( /, �.;�, CO a �® 5' pa
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
D vr1 J, 5,f 1 71/4, 3 v/ tip.. ..
65`0 PawTGib led. tJ -5 -��3
-'
Physical Address,City,and Zip i atur ified Well Contractor or Well Owner Date
FDY S % 6$2Z-t*5'- 3753 By signing this form, 1 hereby cert fy that the well(s) was (were) abandoned in
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 been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36, 0/06 Of67 N e0, Z837Gf 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)ifavailable.For multiple injection 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:
�L Division of Water Resources,Information Processing Unit,
6b.Total well depth: 3 T (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 O (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: OD (ft.) Division of Water Resources,Underground Injection Control Program,
''LL 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): ,T (ft.) 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): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

FORSYTH COUNTY HEALTH DEPARTMENT
7t, Division of Environmental Health
1,1 P.O. Box 686, Winston-Salem, NC 27102
� Nw 336-703-3225
File Number 05/V
® f Lot &Pe Block,
WELL ABANDONMENT RECORD
Contractor 44, fieljet Registration No. Otf
Well Location: (Show a sketch of the site at the right on this form) �J�/) ,2 `" �/
e
eke-
Owner A.A- '4%.0P
Site Address 7i135 ) P 9.-gliik- K. SITE DIAGRAM
5 % Z-7 e- --7 - - - - j - - - - - -- - -
Topography: draw, ;slope,. hilltop, valley, flat
Use of Well P)'fr ., _ Date /'9'75�
Total Depth 311,) Diameter z
Casing Removed:
Feet Diameter
31 "
Sealing Material:
Neat Cement Sand Cement
t
bags cement bags cement //P 1
gals water yds sand fed i
gals water b�
Other: 0
Type material'.
Amount
Explain method of emplacement of material: I�
1 ei►'► & �/�1�y k F9/dhr ®1 ,
FD r CPN 1v65.�o t%�r sOa� ;eito ;;., 1'
gt� INe�1 P., 1 f��i"'� �1+i � O g
I do eby certify ffiat this well abandonment record is
tru= -d a act.
Signa re— ,; ntra tor/Owner Date
' I V—;;)
-ignatur--E.H.S. Date
COPIES:WHITE—HEALTH DEPT. / YELLOW—CONTRACTOR / PINK—HOMEOWNER ' Rev&Reset FCPS 1-22-2014

WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
J. Michael Venable 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 its needed. Indicate TOTAL NUMBER of
NCWC-2079-A wells abandoned: 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 140 (gal.)
Venable Brothers Well Const., Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H pochlorite
7c.Type of disinfectant used: YP
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 5 oz '
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural InMunicipal/Public c 0 Neat Cement Grout ' . 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ; 0 Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout ❑Gravel
Non-Water Supply Well: ❑_Bentonite Slurry_ 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation well mix - 1.5 yards
❑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 s r �'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
removed plumbing; chlorinated �, ,L.. i V D
dewatered via tremie pipe; DEC4.Date well(s)abandoned: 12/11/23 filled with well mix,to top of casing �C ZUZ3
5a.Well location: h � ICbiortien�3iR• ;f}�oat
PARKWOOD MHP II, LLC •
Facility/Owner Name Facility IDt(if applicable) 8.Certification:
338 BARNES RD., WINSTON-SALEM, NC 27107 12/11/23
Physical Address,City,and Zip S' ture of Certified Well Contractor or Well Owner Date
Forsyth 6832-77-7418 By signing this form, 1 hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15,4 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 longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one let/long is sufficient) 9.Site diagram or additional well details:
36.019328 N -80.225872 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)ifavailable.For multiple injection 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:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 120 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6-5/8 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: I '
27 Division of Water Resources;Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft,) 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 courity health department of the county where
6f.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
l

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
owner -BRIAN MALBOEUF 7a.For GeoprobelDPT or CloseJl-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 G V-30 is needed. Indicate TOTAL NUMBER of
N/A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):45 (gal.)
N/A FOR WATER SUPPLY WELLS ONLY:
Company Name 70% HTH
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(Le.UIC.County,State,Variance,etc.)if known
7d.Amount of disinfectant used: 3 OZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) •Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) • Concrete Grout 0 Drill Cuttings
Olrrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ORecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation CONCRETE GROUT 3 YARDS
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of,the abandonment procedure:
❑Geothermal(Closed Loop) OTracer removed plumbing, chlorinated, filled with
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g)
well mix concrete, dug down and removed conc.
4.Date well(s)abandoned: 12/14/2023 casing, poured conc. lirk Aoerw Ip,p2
5a.Well location: covered over.
BRIAN MALBOEUF nce n rb nnnn k o LU1.,)
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1815 W. MOUNTAIN ST KERNERSVILLE 27284 `` Dwa� c142/14/2023
Physical Address,City,and Zip Si • of eC rtified W Cont or or Well Owner Date
FORSYTH 6876-19-5919 By signing this form, I h eby certify that the well(s)was(were) abandoned in
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 been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.135362 N 80.112359 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)ifavailable. For multiple injection 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:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 29 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
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: 26 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
29 10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
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): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016

FORSYTH COUNTY HEALTH DEPARTMENTI
:,.' Division of Environmental Health
i �a P.O. Box 686, Winston-Salem, NC 27102
.. . PiN-0 &96-19�919
��ma:,t, Y 336-703-3225
;iYi • File Number go3oec
�`' ' =.T��` --J Lot all. Block,c '4
WELL ABANDONMENT RECORD
Contractor. .A.A..)Ntr --
Registration No. I n 11
Well Location: (Show a sketch of the site at the right on this form)
i
36.13536a ® 1`1
PLO. //c2 359 ° W
Owner.Brian Irnci9 6,0etrc.
Site Address_ ) I S w, rn n sil U) 604441 54
Topography: draw, ope, hilltop, valley, flat
Use of Well . 6 i=D .. Date 'Ad
O•
.
Total Depth : . 3 1 Diameter '
Casing Removed:
Feet Diameter
3 ao" /
Sealing Material: I( SI
Neat Cement Sand Cement /6#441146 r ��/ Qd
Zot,3
bags cement bags cement i I n ill li I l
4
gals water yds sand r
gals water _ _ _ __ _ _
Other:
Type material. nc, we-11 mi Y _
Amount
Explain method of emplacement of material: I '
i
,
I do hereby certify that this well abandonment record is
true and xact. i
• `a(tALe.
"' � Date I 1
Si a re .H.S.
1I

• WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Owner-George Law 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
N/A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 30 (gal.)
N/A FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: 70% HTH
2.Well Construction Permit#:
N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 9 OUNCES
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 0 Neat Cement Grout 0 Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) IEResidential Water Supply(single) 0 Sand Cement Grout IN Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation CLEAN CLAY 5 YDS
❑Aquifer Storage and Recovery 0 Salinity Barrier CONCRETE CAP .75 YDS
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 0 Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer pumped out water, chlorinated, filled with
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g)
clay packed in 5ft lifts, dug down and removed
4.Datewell(s)abandoned: 12/13/2023 casing poured conc. plug over well,
5a.Well location: co.vered over with dirt.
GEORGE LAW V L !'
Facility/Owner Name Facility lD#(if applicable) 8.Certificat'on:
DEC 2 39P3
3655 TRANSOU RD PFAFFTOWN 27040
Physical Address,City,and ZipS tort of Certified Well Con ctor o $11"ri 1 r ^: . o Re
FORSYTH � [�•d�i ►+ ��
By signing this form, I hereby certify that the well(s)was(were) abandoned in
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 been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.164351 N 80.362393 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)if available.For multiple injection anon-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 II)#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 60 (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: 44 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing lengttlif known): 60 (ft.) 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): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

'try'orb FORSYTH COUNTY HEALTH DEPARTMENT
Division of Environmental Health
-T, P.O. Box 686, Winston-Salem, NC 27102
` :4'.F, y' ' in 336-703-3225
Kii,414,JA;v:W. File Number 3Ier--(0(
4Y` /. Lot 4 Block (!9"a-1
WELL ABANDONMENT RECORD
Contractor 1. EXtettle-s9 - Registration No. (1 irq
Well Location: (Show a sketch of the site at the right on this form).
•
3 . 16yB5I c"NI
+ �� BO-_36 53° VJ
Owner r�jz-2�{ L�i�—Y�i� �. II •
.
Site Address co_� d` /1 o_h -� (Ar
Topography: draw, slope, hilltop, valley, flat
Use of Well k'��5 Date Pt�e���'`�
Total Depth 0Diameter 3'�u t,..1e�11
Casing Removed:
Feet Diameter
3 A®"
Sealing Material: ,
Neat Cement Sand Cement "Sr0.\\
bags cement bags cement
gals water yds sand 17"
gals water '
J
Other:
Type material e.`Q.Gn C I c f
Amount App k 5 rrici c -
Explain method of emplacement of material:
rair.PAD coosvt. \ Aloof'YJ
Eil\-42_ ,( the-f- 't Yi(31 ct ,
I do hereby certify that this well abandonment record is
true and exa .
e__. I Cit,....,--- /7"03-Z5 \I
Signet Contr ctor/Own r P "23at
/40
12i13/
gala e-E.H . Date