Forsyth_Well Abandonment_20240910 (7)

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 I 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): 98 (gal.)
Venable Brothers Well Const., Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
7c.Type of disinfectant used: Calcium
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifbrown
7d.:*:mount of disinfectant used: OZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑ Sand Cement trt'T ; ���I�IIiy Clay
❑industrial/Commercial ❑Residential Water Sup
ply(shared) ■Concrete Gnt Z�— ❑Drill Cuttings
❑irri tion ❑Specialty Grout c C P 1 O 2024❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry J C ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each m C y�dfi�ilr� f ovide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation well mix- 1.25 yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage clean clay- 1 yard
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/CoolingReturn ❑Other(explain under 7 ) removed plumbing; d ew a t e re d;
chlorinated; removed top 3 ft of tile;
4.Date well(s)abandoned: 8/6/2024 filled with well mix to form
_ plug;
sa.Well location: topped with clean clay
KEYSTONE GROUP
Facility/Owner Name Facility lD#(if applicable) S.(ertificatiun:
4540 EBERT RD WINSTON SALEM NC 27127 Q. 7; 8/6/2024
Physical Address,City,and Zip Signatt4ft Certified Well Contractor or Well Owner Date
Forsyth 6812-35-6868 sn fy ) r
By signing rn this form, I here carts that the wells( was were abandoned in
County Parcel Identification No.(PIN) accordance with 1 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.
(if well Grl,l one lat/long is sufficient) 9.Site diagram or additional well details:
36.012586 N -80.306314 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.
10s. 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: 17 (it) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For infection Wells: in addition to sending the form to the address in 10a
6e.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: 1 1 (ft) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (it) 10c.For Water Sunoly&Injection 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): (it) abandoned.
6g.Screen length(if known): (it)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016