Forsyth_Well Abandonment_20240610 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lawrence D. Opper 7a.Number of wells being abandoned: 2
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
3322-A construction/abandonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gaL)
Regional Probing Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permit,n r r ounfy,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 ❑MunicipaUPublic ❑ Neat Cement Grout m 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` ', . , t� ' Qvel
Cuttings
❑Irri tion ❑ Specialty Grout
Non-Water Supply Well: ❑ Bentonite Slurry J U I V 1 Q 4C4❑ Other(explain under 7g)
OMonitoring ❑Recovery L.
Injection Well: 7L For each material selected above. provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation bentonite chips:1.6 Ibs/ft(78-89 Ibs/well)
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage --
❑Experimental Technology I]Subsidence Control 7g.Pros ide a brief description of thr abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Filled/ hydrated from bottom-up. Capped with concrete.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) —
MW-4(49'), MW-5(56')
4.Date well(s)abandoned: 5r'1/2024
JL'11i l 4 ��i
5a.Well location:
A Cleaner World DSCA ID# 34-0012
Facility/Owner Name Facility ID#(ifapplieable) 8.('ertification:
3251 Healy Drive, Winston-Salem Lawrence Opper - 5/1/2024
Phy,ical Wdre—Cm,and Zip Signature of Certified Well Contractor or Well Owner Date
Forsyth By signing this form, /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 longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.0759115 80.3047654 You may use the back of this page to provide additional well site details or well
N 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)if available. l;br multiple injection or non-water supply
wells ONLY with the same construcnon/abandonment,you can submit one form. 10s. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-4, MW-5 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
49-56 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
well I.D.=2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
approx 40 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: Ift.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Sunoly& Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
611 Inner casing/tubing length(if known): 39-46 (ft.) where abandoned.
6g.Screen length(if known): 10 00
f onu G W-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013