Forsyth_Well Abandonment_20240910 (6)

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
NCWC-2079-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in Aell(s): 212 (gal.)
Venable Brothers Well Const., Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H pochlorite
7c.Type of disinfectant used: Calcium
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UJC,County,State,Variance,etc.)((known
7d.Amount of disinfectant used: OZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑A cultural ❑Munici al/Public ❑Neat Cement G t . !' (r 'Bentonite Chips gn P s or Pellets
� .
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ❑ Sand Cement Grout 1 'ry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) F Concrete Grout S E P 1 0 20240 Drill Cuttings
01ri tion ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slulf*'+tT�i;f ��rr- ;; �ftr(explain under 7g)
❑Monitoring ❑Recovery, D`Nid'`OG
Injection Well: 7f.For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑GroundwaterRemediation well mix - 8 yards
[]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 removed plumbing; dewatered;
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7
chlorinated; removed top 3 ft of tile;
4.Date well(s)abandoned: 8/29/2024 filled with well mix to form plug;
9;
Sa.Well location: topped with clean clay
WESTCAR PROPERTIES,LLC/FRANK HERNANDEZ
Facility/Owner Name Facility ID#(if applicable) S.Certification:
7113 HUNTING BROOK CT., WALKERTOWN, NC 1/o�y� 8/30/2024
Physical Address,City,and Zip SigntO6 ofCettified Well Contractor or Well Owner Date
Forsyth 6869-74-1021 y g f y fy ()
B signing this o /hereby certify that the wells was were abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 01C.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.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.201204 N -80.128137 K 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,
61).Total well depth: 64 (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: 24 (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: 51 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (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 the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016