Forsyth_Well Abandonment_20240731 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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 is needed. Indicate TOTAL NUMBER of
N CWC-2079-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 158 (gal.)
Venable Brothers Well Const., Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
2.Well Construction Permit#:
17049 7c.Type of disinfectant used: Calcium
List all applicable well construction permits(i.e.UIC.Coumh,,State. Variance,etc.)ifknoxm 4 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) a Resjdcatial Water Supply(single) ❑ Sand Cement Grout a Dry Clay
❑Industrial/Commerci ` �1{gtcjoAal Water Supply(shared) s Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: I� 3 _ ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recov
Injection Well: 'Ir f£;r,�;s, 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge S'-FrroundwaterRemediation well mix - 1 yard
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage clean clay - 1 yard
❑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) Chlorinate well; dewatered via tremie pipe;
filled well with 1 yard of well mix;
a.Date well(s)abandoned: 7/9/2024 pour cement plug; top with clean clay.
5a.Well location:
Aaron Griffith/Daniel Ben Barker
Facility/Owner Name Facility ID#(if applicable) S.Certification:
1723 Brookford Rd., Kernersville, NC 1/ .6� 7/15/2024
Physical Address,City,and Zip Signat 47tCertifed Well Contractor or Well Owner Date
Forsyth 6885-80-3403 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
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:
36.082151 N -80.054717 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 records)ifavailable. For multiple injection ornon-watersupply ivells
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: 142 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter: 6 (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: 37 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 1 Oc.For Water Supply&Iniection 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