Forsyth_Well Abandonment_20230602 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lawrence D. Opper 7a.Number of wells being abandoned: 10
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
3322-A construction/abandonment,you can submit one fornt.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
Regional Probing Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.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 t.-�:-.;= ❑ Bentonite Chips or Pellets
r ..-,,.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement roufb-- ..c f' 5_E,Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout I I (, 0n ❑Drill Cuttings
❑ Specialty Grout Jl,iv V 2l'ZJ ❑Gravel
❑Irri anon P tY
Non-Water Supply Well: ❑ Bentonite SitIiFr �ther(explain under 7g)
❑Monitoring ORecovery :rr�'�::' ;.�.
Injection Well: 7f.For each material selected agove,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 2"MWs:1.6 Ibs/ft (32-45 Ibs/well)
❑Aquifer Storage and Recovery ❑Salinity Barrier Bentonite 4"SVE-1:6.3 Ibs/ft (50lbs)
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer MW-1 (23%MW-2(22'),MW-3(25%MW-4(26'),MW-4A(20'),MW-5(20')
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
MW-6(20%MW-11 (20'),MW-14(27.5),MW-16(28'),SVE-1 (4"x8.5')
4.Date well(s)abandoned: 5/4/2023
5a.Well location:
AMI, LLC
Facility/Owner Name Facility ID#(ifapplicable) $•Certification:
2609 Tucker Street Extension, Winston-Salem Lawrence Opp r,,�. w 5/15/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Forsyth By signing this form, I hereby terrify 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.061267 N 79.453537 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Aaach 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 ID#: See 7g abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 20-130 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: well I.D.=1-4(in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
approx 10 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
1Oc. For Water Supply&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.
6g.Screen length(if known): (ft.)
Foam G W-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013