Forsyth_Well Abandonment_20230227

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS!
Mike Tynan 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
2725-A Y^^ ^" M wells abandoned:
;x,. 4:..-..—"'
e "_' " r s""° '�� L. J 7b.Approximate volume of water in well(s): ~70
NC Well Contractor Certification Number FEBt1 PP remaining (gal.)
!ET B 2 7 2023 FOR WATER SUPPLY WELLS ONLY:,
Company Name ,,- , 70% hypochlorite
lnfOr a;+� zn : rz .,,5:.d>ir,Q Ulr i1 7c.Type of disinfectant used:
2.Well Construction Permit#: J r"IQl SOt
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 3 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 P Neat Cement Grout U Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) !Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) P Concrete Grout 0 Drill Cuttings
❑lrrigation 0 Specialty Grout P Gravel
Non-Water Supply Well: _ _.❑_BentoniteSlurry _ QOther(explain.untlrr 7g) _ .
OMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation portland cement 2068 lbs gravel 1.3 cu yds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwaterlhainage concrete.800 lbs bentonite 100 lbs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Removed all piping. Disinfected well. Removed upper 3 ft of casing.
Filled well from 15 ft to 30 ft with gravel and neat cement. Filled 3 ft to 15 ft
4.Date well(s)abandoned: 2/16/2023 of well with neat cement(5% bentonite).
5a.Well location: Filled 0 to 3 ft with concrete.
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
106 S. Gordon Drive, Winston-Salem 27104 "7/14. 2/16/2023
Physical Address,City,and Zip Signature of Ce ed Well Contractor or Well Owner Date
Forsyth i.
By signing this form, I hereby certifr 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 beef provided to the well owner.
5b.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:
36.089162 N -80.318095 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 record(s)if available.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 1D#: WSW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
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10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 16 (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: 23 (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 Sunnis,&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
6E Inner casing/tubing length(if known): (ft.) abandoned.
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6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016