Forsyth_Well Abandonment_20230724

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
NCWC-2079A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water.remaining in well(s): 496 (gal,)
VENABLE BROTHERS WELL CONST., INC. FOR WATER SUPPLY WELLS ONLY:
Company Name CALCIUM HYPOCHLORITE
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e. UIC,County,State,Variance,e1C.)fl(noWn 1 5 OZ
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation WELL MIX: 5 YARDS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under 7g) REMOVED PLUMBING; CHLORINATED;
DEWATERED; REMOVED 3 FT TILE;
a.Date well(s)abandoned: 7/5/23 FILLED WITH WELL MIX; POURED PLUG.
5a.Well location: _
ELADIO ACUNA - P P�� 3 ��'D
Facility/Owner Name Facility ID#(ifapplicable) S.Certification: JUL d A 2023
2419 CAUDLE ST., GERMANTON, NC 27019 t1gsX4 7/5/23
Physical Address,City,and Zip S' ature of Certified Well Contractor or Well O% flf .
°"� , � a2w'fiDt
FORSYTH 6931-23-4418 _ D%-'ry1?r6G
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
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.253587 N -80.246573 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
Aaaclrwellconsintctionrecord(s)ifavailable. For multiple irjectionornon-water supply wells
ONLY with the same cotsn•actionlabandatnnent,you can subunit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 55 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Injection 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: 24 (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (pt) 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
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