Forsyth_Well Abandonment_20230515 (4)

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. htdicate TOTAL NUMBER of
wells abandoned:
NCWC-2079-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):165 (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 11-ell cunstnictiun permits(i.e. UIC,County,Slate,lariance,etc.)ifknown 5 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 ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) PResidential Water Supply(single) ❑ Sand Cement Grout e Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) iN Concrete Grout ❑ Drill Cuttings
OIrrijzation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amou of materials used:
❑Aquifer Recharge ❑Groundwater Remediation well mix - 5 yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
QAquiTer Test OStormwater Drainage clean clay-1 yard MAY �� _
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonmenn pwcedurrr:,",f,.
❑Geothermal(Closed Loop) ❑Tracer r ' Cg$:CN liil;t
❑Geothetmal(Heating/Coolin Return) ❑Other(explain under7 ) removed plumbing; dewatered; "-va"13G
chlorinated; removed top 3 ft of tile;
a.Date well(s)abandoned: 3/16/23 filled with well mix to form plug;
5a.Well location: topped with clean clay
WEiDL PROPERTIES LLC
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
4860 GRUBBS RD., WALKERTOWN, NC %2 - Z3
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Forsyth By signing this form, 1 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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
tif...cl)field one lat9ong is suffici=-O 9.Site diagram or additional well details:
36.205139 N -80.132640 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
Anach it-ellconstruction reeord(s)ifavailable. for multiple hyeclionor non-water.supplvwells
ONLY with the same consinictton abandomnent,you can submit one.form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well►DN: abandonment to the following:
Division of Water Resources,Information Processing Unit,
613.Total well depth: 50 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection 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: 40 (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 Sunoly&Iniection 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 GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016