Forsyth_Well Abandonment_20240205

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
ADAM SPEAR 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
/A wells abandoned:
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NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): DRY (gal.)
rn /A FOR WATER SUPPLY WELLS ONLY:
Company Name N/A
2.Well Construction Permit#:
FI LE#402997 7e.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)if known N/A
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) IRResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water.Supply_Well: ;--- - -- -- - - ❑gentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation CONCRETE GROUT 12-/3YDS APPX.
❑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 WELL FILLED WITH CONCRETE GROUT,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
DUG OUT AND REMOVED BRICK LINING
4.Date well(s)abandoned: 1/11/2024 POURED CONC. PLUG OVER WELL,
Sa.Well location: COVERED OVER
SPEAR CHERRY ST.HOLDINGS,LLC
Facility/Owner Name Facility ID#(if applicable) S.Certification:
102 S. CHERRY ST W-S 27101 1/18/2024
Physical Address,City,and Zip Signature of Ccr ell tractor or Well Owner Date
FORSYTH 6835-15-6483 "
By signing this form,I 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:
(if well field,one let/long is sufficient) 9.Site diagram or additional well details:
36.094264 N 80.246890 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 weliconstructionrecord(s)ifavailable.For multiple hyectionor•non-water•supplvwells
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)D# aband6nment to the following:
q Division of Water Resources,Information Processing Unit,
6b.Total-well depth: 48 M.) �p t 1617 Mail Service Center,Raleigh,NC 27699-1617
40bi I*Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: �i (in.) If+�C�f=" C.. rZ 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: DRY (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.For Water Supply&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

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FORSYTH COUNTY HEALTH DEPARTMENT
Division of Environmental Health
P.O. Box 686, Winston-Salem, NC 27102
336-703-3225 � � �
I N-W-6066-1Z - 01463
File Number 410299�
Lot P08 Block 70
WELL ABANDONMENT RECORD
Contractor 0wcg=- AJ.-cm Registration No. LA.
Well Location: (Show a sketch of the site at the right on this form)
3hh6. 03'gZ6z-/ All
Owner • .._ _. _ CXJ*2y����o �
J P - _L 6 c
Site Address s+
I �4 On. SQQ ova C.,. ISO 110.1
Topography: draw, slope, hilltop, valley, flat 6' Cherry 5
Use of Well Date
Total Depth Diameter
Casing Removed:
Feet Diameter
/ "3(o'.
Sealing Material:
Neat Cement Sand Cement
bags cement bags cement
gals water yds sand gals water water V" . pil-
Other: 5 -tCJ ej
h
Type material Can=, LjmlI te„-
Lie-li
Amount la - P 3 va-ZA3
Explain method of emplacement of material: py
WWI
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I do hereby certi .thpt'th' well abandonment record is
true and exact. / �
Signature-Contractor/Owner ; ate
'Date
Sig _ ture— S.
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