Forsyth_Well Abandonment_20240212

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Timothy D. Leatherman 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
2888A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):_(,-at.)
Pyramid Environmental and Engineering, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: NA
List all applicable well construction permits(i.e.VIC,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 III Neat Cement Grout a 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)
C Monitoring ❑Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑GrotmdwaterRemediation 25 Pounds Bentonite 5 Pounds Portland
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Chips/Pellets Grout Cement
❑Experimental Technology ❑Subsidence Control
7g. Proside a brief deuription ofthe abandonment procedure:
❑Geothermal(Closed Loop) []Tracer
(Heating/Cooling❑Geothermal Return) ❑Other(explain under7 ) Slow pour bentonite and trimie pipe/slow pour
grout cement.
4.Date well(s)abandoned: 02/07/2024
5a.Well location:
Thomas Morrison NA
Facility/Owner Name Facility ID#(if applicable) 8.C�'tification:
4198 N. Cherry St., Winston-Salem, NC .�A;A Co 02/07/2024
Physical Address,City,and Zip Signature o£Cert ed Well Contractor or Well Owner Date
Forsyth 6827-63-4981 By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with l SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.144755 N -80.265369 `` 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#: M W-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 17.5 (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: 8(2-Inch dla)(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: 16.0 (ft) Division of water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) 10c.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 tJVE 11 the county where
5 abandoned. U
6f.Inner casing/tubing length(if known): (ft.) h y
FEB 1 2 2024
6g.Screen length(if known): 12.5 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016