Forsyth_Well Abandonment_20230104

i
SELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used fbr single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MICHAEL VENABLE 7a.Number of wells being abanidoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple bjectlon or non-ivater ertpply µells ONLY µith the same
construction/abandonment,,you can srlbmit one form.
N CWC-2079—A
7b.Approximate volume of water iremaining in well(s): 100 —(gal.)
NC Well Contractor Certification Number j
VENABLE BROTHERS WELL CONST., INC. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: CALCIUM HYPOCHLORITE
2.Well Construction Permit#:
List altapplicable ivell permits(i.e.County,State,Variance,lnjection,etc.)ifknoum 7d.Amount of disinfectant.used 3 OZ
3.Well use(check well use):
i•
Water Supply Well: 7e.Sealing materials used(check all that apply):
nAgricultuml nMunieipaMblic r-+Neat Cement G�°ut�, .. � 4,,Q.Hcutonite Chips or Pellets
nGeothermal(Heating/Cooling Supply) EResidential Water Supply(single) n Sand Cement T--up"i,�s li:;�s 'ay' _I` Clay
Residential Water Supply(shared) 9 Concrete Grout
❑Industrial/Commercial n Drill Cuttings
J�� � 'G ����—
❑Irri ation ❑ Specialty Grout - n Gravel
Non-Water Supply Well: ❑Bentonite SI�trOtt�I ``t`t �t3nilPt
er(explain under 7g)
nMonitoring nRecovery '�+ `OrpJ0
Injection Well: 7E For each material selected above,provide amount of materials used:
nAquifer Recharge nGroundwater Remediation WELL MIX;3 YARDS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwatcr Drainage
OExperimental Technology n Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) nTracer 11
REMOVED PLUMBING;DEWATERED;CHLORINATED;
DGeothermal(Heating/Cooling Return) ❑Other(ex lain under 7g)
REMOVED 3 FT TILE;FILED WITH WELL MIX;
11
4.Date well(s)abandoned: 7j26122 POURED PLUG; COVERED WITH CLEAN CLAY
5a.Well location:
MYRA AULT
Facility/Owner Name Facility fD#(if applicable) 8.Certifications: ,
-7•2
1609 HWY 66S,KERNERSVILLE, NC %�%�' a'ZZ
Physical Address,City,and Zip Signature of Certified Well Contractor'or Well Owner Date
FORSYTH By signing this form. I hereby certify that the well(v) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 NCAC 02C,'.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has,been provided to the well ow7ter.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(r•Pwvit nerd,o=htdfing is sutricicnt) 9.Slte diagram or additional weR details:
36.082218 80.063610 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 WELLISI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLYwith the same constructionlabandonment 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.Totalwell depth:35 (ft) 1617 Mail Service;Center,Raleigh,NC 27699-1617
;.
10b.For Injection 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:
29 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service!Center,Raleigh,NC 27699-1636
i
10c.For Water Sunaiv&Iniection 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
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
i
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
• 1

r
,. ELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MICHAEL VENABLE 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple izjection or non-ulster supply wells ONLY svith the same
construction/abandonment,you can sttWitt one form.
N CWC-20.79—A
NC Well Contractor Certification Number 7b.Approximate volume of wat`erlremaintng in well(s):200 (gal.)
.VENABLE BROTHERS WELL CONST., INC. FOR WATER SUPPLY WELLS',ONLY:
Company Name 7c.Type of disinfectant used: CALCIUM HYPOCHLORITE
2.Well Construction Permit#1:
List all applicable well permits(i.e.County,State,Yariance,liltection,etc.)if kztotvn 7d.Amount of disinfectant used: 6 OZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
FlAgricultural mMunicipal/Publie El Neat Cement Grout n Bentonite Chips or Pellets
r7Gcothetmal(Heating/Cooling Supply) EResidential Water Supply(single) 0 Sand Cement Gr fry1(C Cuttings
Clay
' + -• n
❑Industrial/Commercial !� Concrete Grout
Residential Water Supply(shared) a
12Itri ation n Specialty Grout J A y 0 G 20 L Gravel
Non-Water Supply Well: ElBentonite Slurry D Other(explain under 7g)
I,
riMonitoring r"Recovery <:t �r1
Injection Well: 7f.For each maTseieceliMovide amount of materials used:
FiAquifer Recharge n Groundwater Remediation WELL MIX:4YARDS
DAquifer Storage and Recovery OSalinity Barrier
DAquffcr Test OStormwater Drainage
i
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
nGeothermal(Closed Loop) Tracer REMOVED PLUMBING; DEWA I EKED;CHLORINATED;
DGeothermal(Heating/Cooling Return) El Other(explain under 7g)
REMOVED 3 FT TILE;FILLED WITH WELL MIX;
4.Date well(s)abandoned: 7/26l22 POURED PLUG;COVERED WITH CLEAN CLAY
5a.Well location:
MYRA AULT 1t
Facility/Owner Name Facility ID#(if applicable) S.Certitieation:
1605 HWY 66S,KERNERSVILLE,NC
Physical Address,City,and Zip Signature of Certified Well Contractor'or'Well Owner Date
1
FORSYTH
By signing this farm, I hereby cetkfy that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with I SA NCAC 02C;0100 or 2C.0200 Yi ell 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:
(tftratt Seld,ane fanrong is sufficient) 9.Site diagram or additfonal weU detafls:
36.082458 80.063637 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. For multiple injection or non-water supply
wells ONL➢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: 1
Division of Water Resources,Information Processing Unit,
6b.Total well depth:42 (fG) 1617 Mail ServiceCenter,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
20 above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: on.) abandonment to the following:
31 Division of Water Resources,,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail ServkeeiCenter,Raleigh,NC 27699-1636
10c.For Water Sunnly&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also subinit one copy of this form within 30 days of
completion of we))abandonmen[to the county health department of the county
where abandoned.
6f.Inner casing/tubing length(if known): (ft.)
I
6g.Screen length(if known): (ft)
I
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
1 I

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MICHAEL VENABLE 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property)
For multiple infection or non-ivafer supply wells ONLY with the same
consmuctlon/abarrdaanient,you can sub»tit one jonn.
N CWC-2079-A
7b.Approximate volume of water remaining in well(s): NIA (gal.)
NC 11rell Contractor Certification Number I
VENABLE BROTHERS WELL CONST., INC. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: CALCIUM HYPOCHLORITE
2.Well Construction Permit#:
List all applicable xrll permits(i.e.County,State,Variance,Ir jection,etc.)if/otown 7d Amount of disinfectant used.
NIA
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
nAgricultural mMunicipal/Public ❑Neat Cement Grout n Bentonite Chips or Pellets
FiGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑ Sand Cement Grout n Dry Clay
0Industrial/Commercial DResidential Water Supply(shared) Rl Concrete Grout 0 Drill Cuttings
❑Ini ation E2 Specialty Grout n Gravel
Non-Water Supply Well: ❑Bentonite Slurry 11 Other(explain under 7g)
nMonitoring rlRecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
MAquifer Recharge nGroundwaterRcmediation WELL MIX:6 YDS
13Aquifer Storage and Recovery ❑Salinity Barrier
DAquifer Test DStormwater Drainage
DExperimental Technology DSubsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) nTracer REMOVED 3 FT TILE;FILLED WITH WELL MIX;
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
POURED PLUG;TOPPED WITH CLEAN CLAY
4.Date well()s abandoned: 6/9I22 7. ., i. "-
-� 1
5a.Well location:
STEVEN GWYN iA11 -
Facilit/Owner Name Facility ID#(if applicable) S.Certification:
•CI `/
4976 DOCK DAVIS RD.,CLEMMONS, NC 27012 Dkpel C&Q
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
FORSYTH I
By signing this for�r:, I hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C 1.0100 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: j
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.988108 -80.384340 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 consnverion records)if available. For multiple it jection or non-water supply
rrells ONLY with the same construction/abandonment,you can submit one forin. 10n. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID#:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:60 —(ft.) i.
1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
20 (ln•)
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: abandonment to the following:
' I
NO WATER Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
I
10c.For Water Sunnly&Iniection 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
where abandoned.
6f.Inner casing/tublug length(if known): (ft.)
I
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
I

WELL ABANDONMENT RECORD For Internal Use ONLY!
This form can be used for single or multiple wells
1,Well Contractor Information: WELL ABANDONMENT DETAILS
il
JAMES MICHAEL VENABLE 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple uyection or non water supply wells ONLY with the same
constractioitlabaiidortrsteat,you can submit one form.
N CWC-2079—A
7b.Approximate volume of water remaining in well(,): 375 (gal.)
NC Well Contractor Certification Number
VENABLE BROTHERS WELL CONST., INC. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: GAL'CIUM HYPOCHLORITE
2.Well Construction Permit#:
List all applicable well permits(i.e.County,State,I'ariance,h jection,etc.)ifblown 7d.Amount of disinfectant used: �2 OZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
(Agricultural rlMunicipal/Public 11 Neat Cement Grout 0,Bcntonite Chips or Pellets
riGeothermal(Heating/Cooling Supply) EResidential Water Supply(single) n Sand Cement Grout D Dry Clay
ElIndustrial/Commercial OResidential Water Supply(shared) El Concrete Grout D Drill Cuttings
❑Irri ation ❑ Specialty Grout 11 Gravel
Non-Water Supply Well: ❑Bentonite Slurry n Other(explain under 7g)
rIMonitoring nRecovery
Injection Well: If.For each material selected above,provide amount of materials used:
FlAquiferRecharge nGroundwaterRemediation WELL MIX:6 YARDS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 0Subsidence Control 7g,Provide a brief description of the abandonment procedure:
E2Gcothermal(Closed Loop) ❑Tracer DEWATERED;CHLORINATED;FILLED WITH CONCRETE;
DGeothermal(Heating/Cooling Return) El Other explain under 7g)
REMOVED CASING; POURED PLUG;TOPPED WITH CLEAN
6/7/22
4.Date well(s)abandoned: CLAY �" ;, ,a L....4 ?� 'r^'
Sa.Well location: I Ay 0 G 2023
WEIDL PROPERTIES y Y ( applicable) 8.Certification: I lni;;Si � C.l?rr.• Una
Facility/Owner/Owner Name Facilit ID# ifa licable / ^�+?e'C2/uOG
FORTNIGHT RD.,PFAFFTOWN, NC 27040 `G % — 7,
Physical Address,City,and Zip Signature of Certified Well Contmetor,or Well Owner Date
FORSYTH By signing this fotnz, 1 hereby certfy that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance tvitlt 15ANCAC 02C;:0100 at-2C.0200 Well Conshuction 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:
(if well field,one far/long is sufficient) 9.Site diagram or additional well details:
36.156217 -80,383823 You inay use the back of this page to provide additionribwell sit.details or well
INW 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. For multiple injection or non-water supply
wells ONLY ivith the same constructiaidabandonment,you can submit one farms. 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,
57 1617 Mail Service'Center,Raleigh,NC 276994617
6b.Total well depth: (ft)
10b.For Injection Wells: In addition to sending the form to the address in l0a
20 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
34
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft•) 1636 Mail Service,'Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniectlon Wells: In addition to sending the form to
6c.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
where abandoned.
6f.Inner easing/tubing length(if]mown):
I .
6g.Screen length(if known): (ft.) I
i
Form GW-30 North Carolina Department of Environment and Natural Resources—DivisIon of Water csources Revised August 2013

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MICHAEL VENABLE 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property)
For multiple ejection or non-water supply ivells ONLY Wth the same
consnwctimi/a&mrdornrent you can submttionejornr.
N CWC-2079—A
7b.Approximate volume of water remaining in well(s):275 (gal.)
NC Wei Contactor Certification Number >
VENABLE BROTHERS WELL CONST., INC. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: CALCIUM HYPOCHLORITE
2.Well Construction Permit#:
List all applicable well permits(i.e.Comity,State,Variance,hjection,etc.)ifknonnr 7d.Amount of disinfectant used.* 9'OZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
npgricultura] nMunicipallPublic —
Neat Cement Grout n Bentonite Chips or Pellets
rlGeothermal(Heating/Cooling Supply) Mesidential Water Supply(single) n Sand Cement Grout n Dry Clay
_ ❑Residential Water Supply(shared) Z Concrete Grout 0 Drill Cuttings
,lndustriaVCommercial PP Y( ,
n Specialty Grout n Gravel
01ni ation
Non-Water Supply Well: ❑Bentonite Slurry n Other(explain under 7g)
rIMonitoring rlRecovery
Injection Wen: 7f.For each material selected above,provide amount of materials used:
FlAquifer Recharge n Groundwater Remediation WELL MIX:4 YARDS
ElAquifer Storage and Recovery ❑Salinity Barrier
"Aquifer Test ❑Stormwater Drainage
nE erimental Technology ❑Subsidence Control
_ xp gY 7g.Provide a brief description of the abandonment procedure:
17Geothermal(Closed Loop) ❑Tracer REMOVED PLUMBING;DEWATERED;CHLORINATED
OGeothermal(Heating/Cooling Retum) I]Other(explain under 7g
FILLED WITH WELL MIX TO SLE FLSH�W}!dt Dl?IVEWAY
4.Date well(s)abandoned. 6/3/22 ^-s b
5a.Well location: 1 Q
AMERA NADKERNI/PROGRESS EI Irno�lx k3�n Pf..� cr3 Una
Facility/Owner Name Facility ID#(if applicable) $•Certification: Dy,1Q/-,00
l{g Lir1 ber*NST.,WINSTON-SALEM,NC 21104 C -1-- .2 2
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
FORSYTH 6805-93-6096 By signing this form, I hereby cert6 that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C 10100 or 2C.0200 Well Consimcdon 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: I
(if wall field,one ladiang is sufficient) 9.Site diagram or additional well details:
36-086740 -80.321052 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.
I
I
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
hells ONLY with the same construction/abandonment,you can submit one forte. 10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID#:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:40 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the font to die address in 10a
above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 20 (in.) abandonment to the following:
i ,
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 25 00 1636 Mail Service"Center,Raleigh,NC 27699-1636
10c.For Water SunDly&Injection Wens: In addition to sending the form to
6e.Outer casing length(if known): (ft) the address(es) above, also subiuit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
6f.Inner easing/tubing length(if known): (ft.) where abandoned.
I '
I
6g.Screen length(If known): (ft.)
14
i
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water i Resources Revised August 2013

!
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I '
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MICHAEL VENABLE 7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply uVIls ONLY with the same
construction/abandonment,you can sub»riti one form
N CWC-2079-A
7b.Approximate volume of water remaining in well(s):65 (gal.)
NC Well Contractor Certification Number I j
VENABLE BROTHERS WELL CONST., INC. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: CALCIUM HYPOCHLORITE
2.Well Construction Permit#:
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)ifbiown 7d.Amount of disinfectant used: 4 OZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
MAgricultural rlMunicipal/Public ❑Neat Cement Grout n Bentonite Chips or Pellets
r'Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ❑ Sand Cement Grout D Dry Clay
0Industrial/Commercial [I Residential Water Supply(shared) [?] Concrete Grout n Drill Cuttings
Irrigation ❑Specialty Grout D Gravel
Non-Water Supply Well: n Bentonite Slurry n Other(explain under 7g)
r'Monitoring FIRecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
FiAquifer Recharge MGroundwater Remediation WELL MIX-4 YARDS
❑Aquifer Storage and Recovery ❑Salinity Barrier
Aquifer Test ❑Stormwater Drainage
oExperimental Technology 0Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer REMOVE PLUMBING;CHLORINATE; FILL WITH
DGeothermal(Heating/Cooling Return) 0Other(explain under 7g)
WELL MIX TO WITHINaf FT;,REMOVE TILE;
4.Date well(s)abandoned: 6- 19 - '!z POUR PLUG;TOP WITH CLEAN CLAY
5a.Well location: J AN O
NCDOT 1 ABATEMASTER t, .
n Pir.rr �
Facility/Owner Name Facility ID#(if applicable) 8•Certification: j lrnO; ;.ae ,yam
458 OAK GROVE CH RD.,WINSTON SALEM,NC 27107 '�^ S /c/- ZZ
Physical Address,City,and Zip Signature of Certified Well Contractor,or Well Owner Date
FORSYTH By signing th4v form, Il:ereby 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:
(ifaall field,one latRong is sufficient) 9.Site diagram or additional well details:
36.074769 -80.133924 You inay 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 will construction record(v)if available. For multiple injection or non-water supply '
wells ONLY with the same construction/abandoninent,you can submit one form. 10a. For All Wells: Submit this forth within 30 days of completion of well
abandonment to the following:
6a.Well ID#•
Division of Water Risources,Information Processing Unit,
43 1617 Mail Service'Center,Raleigh,NC 27699-1617
6b.Total well depth: —(It.)
10b.For Injection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 20 (in.) abandonment to the following:
i
38 Division of Water Resources,;Underground Injection Control Program,
6d.Water level below ground surface: (ft.) .1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water SunDIv&Iniel tion Wells: In addition to•sending the form to
6e.Outer casing length(if known): (R) 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
6f.Inner casing/tubing length(if known): (ft.) where abandoned. j
6g.Screen length(if known): (ft.)
I
Form OW-30 North Carolina Department of Environment and Natural Resources—Division of Water,Resew= Revised August 2013