Forsyth_Well Abandonment_20240814

WELL ABANDONMENT RECORD For internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Ronald F. Barron 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
2091-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Piedmont Industrial Services FOR WATER SUPPLY WELLS ONLY:
Company Name 70% HTH Chlorine
7c.Type of disinfectant used:
2.Well Construction Permit#: _
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflmown
7d.Amount of disinfectant used: 3oz
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) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) s Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout. -- t ftr vel
Non-Water Supply Well: ❑Bentonite Slur4 1.9 b11rer(explain under 7g)
❑Monitoring ❑Recovery Injection Well: X For each material Op*d�b4e„ ;Ade amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 4 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 Remove T of soil in a 1" radius around 20"well. Remove
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
3'of 20"concrete well casing and pumbing.Proceeded to place 4 yards
4.Date well(s)abandoned: 8-6-24 from bottom to 6"above well casing and 1'outside
5a.Well location: backfill remaining excavation with soil.
Sagamore Homes NC INC. N/A
Facility/Owner Name Facility 1D#(if applicable) 8.Certification:
3039 Loch Drive, Winston Salem 27106 � �� 8-6-24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Forsyth 6817-44-4879 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.
Sb.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:
36.146885 N 80.305593 �, 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 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#: 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 36 (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: 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: 36 (fh) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
36 10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (fti) address(es)above,also submit one copy of this form within 30 days of completion
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of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): N/A (ft.) abandoned
6g.Screen length(if known): N/A (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT PERMIT �¢ FILE# 416716
FORSYTH COUNTY DEPT. OF PUBLIC HEALTH t PIN# 681744-4879
DIVISION OF ENVIRONMENTAL HEALTH LOT: 101 D BLOCK: 3606
799 NORTH HIGHLAND AVENUE
WINSTON SALEM NC 27102
336-703-3225 WELL: 1 _ OF 1
OWNER/APPLICANT: SAGAMORE HOMES NC INC. / PIEDMONT INDUSTRIAL SERVICES
SITE ADDRESS: 3039 LOCH DR WINSTON SALEM NC 27106
Well Coordinates: N: 36.146885a W: 80.305593°
WELL TYPE: BORED WELL DIAMETER: 20 (inches)TOTAL DEPTH: 36 (feet)
Static Water Level: 36 (feet)
PERMIT CONDITIONS:
Q Plumbing present in well to be removed before abandonment
(D Water in large diameter wells shall be pumped out prior to abandonment
CHLORINATE WELL WITH 70% HTH CHLORINE, FILL WELL WITH WELL MIX CONCRETE OR
CLEAN CLAY PACKED IN 5FT LIFTS, DIG DOWN AND REMOVE ATLEAST 3FT OR CASING
BELOW GRADE, POUR 6" THICK CONCRETE PLUG OVER WELL AND 12" OUT ON THE SIDES.
EHS: MIKE MERRELL II REHS ISSUED DATE: 7/31/20:24
*CERTIFIED WELL DRILLER REQUIRED TO BE ONSITE FOR WELL ABANDONMENT, WELL S-IALL BE ABANDONED PER THE
15A NCAC 02C .0100 RULES, SEE CONDITIONS ABOVE FOR SPECIFIC ABANDONMENT REQUIREMENTS.
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