Forsyth_Well Abandonment_20230526

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Edward Wyl lys Taylor, Jr. 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 2440-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): NA (gal)
Geonetics Corporation FOR WATER SUPPLY WELLS ONLY:
Company Name
NA 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.&VC,County,State,Variance,etc.)ifknown
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) ❑Residential Water Supply(single) ❑ Sand CemQntGz4 t"° ,��,,, ❑Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) s Concrete Grout "'r ° la a,mC7 Drill Cuttings
❑Irri ation ❑ Specialty GrohlAy
2 6 2023 ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
CMonitoring ❑Recovery In(�;rr;�i�l I�t?r S IR ls I r�Yo{rH'-U .�r
Injection Well: 7f.For each materr—aV prWilde amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation NA
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology []Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Removed M W manhole cover
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Observed manhole filled with concrete grout
4.Dare well(s)abandoned: Confirmed 5/16/23
Sa.Well location:
APH Holdings, LLC NA
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
125 W. Hanes Mill Road, Winston-Salem, NC 27105 Edward.W. Taylor,Jr .05/17/23
Physical Address,City;and Zip Signature of Certified Well Contractor or Well Owner Date
Forsyth 6829-20-8331 appears to be
By signing this form,I hereby certify that the well(s) %wR-(WsF44 abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.189300 N 80.277945 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 records)ifavailable.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 ID#: Monitoring Well abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:
as(per NCDOT) (fk) 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: NA (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: NA (fk) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (fk) 10c.For Water Supply&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): NA (fk) abandoned.
6g.Screen length(if known): NA (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resourcesi Revised 2-22-2016

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