Forsyth_Well Abandonment_20230515 (3)

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
wells abandoned:
NCWC-2079-A
NC Wall CoawactorCortification Nwnb" 7b.Approximate volume of water remaining in well(s): 360 gat.)
Venable Brothers Well Const., Inc. FOR WATER SUPPLY W'FI,I S ONLY:
Company Name Yp
Calcium H ochlorite„ _
7c.Type of disinfectant used:
2.Well Construction Permit 4: t ��� L--s V I ;
.-:
List all applicable trell con.viruction perntit.v(i.e. UK',Comity,State, Variance.etc.)ifknowtt 1 1 OZ
7d.Amount of disinfectant used: iIIIt1Y, LEND .
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): 111�GfiY:a:"� 'ar` � +J Uric
r`,t lac•;'
❑Agricultural ❑Municipal/Public ❑Meat Cement Grout ❑ Bentonite Chipj?f%% PG
❑Geothermal(Heating/Cooling Supply) !!Residential Water Supply(single) ❑ Sand Cement Grout s Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) N Concrete Grout ❑ Drill Cuttings
❑irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation well mix -4 yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
DAquifer Test ❑Stormwater Drainage 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 7g)
chlorinated; filled with well mix to form
4.Date well(s)abandoned: 3/10123 plug; topped with clean clay
5a.Well location:
MICHAEL STOVER
Facility/Owner Name Facility ID#(if applicable) 8.Certifiication:
2630 RURAL HALL-GERMANTON RD, GERMANTON,NC 27019
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Forsyth 6931-14-7171 By signing this form, I hereby certify that the ivell(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 ou-ner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifssrtl rwfd.one tatlong is sufficient) 9.Site diagram or additional well details:
36.255122 N -80.248315 W You may use the back of this page to provide additional Weil site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
l each well con.straction record(s)ifavailable. For multiple injection or non-tvatersupply wells
ONLY frith the scone construction abandonment,you can submit one farm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well 1DN: abandonment to the following:
Division of Water Resources,information Processing Unit,
6b.Total well depth: 40 (it.) 161.7 Mail Service(-'enter,Raleigh,NC 27699-1617
10b. For Infection 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:
6d.Water level below ground surface: 18 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (fk) 10c.For Water Sunnh,&Injecton 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