Forsyth_Well Abandonment_20240212 (2)

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
N C W C-2079-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 52 5 (gal.)
Venable Brothers Well Const., Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H\/ ochlorite
7c.Type of disinfectant used: Calcium
2.Well Construction Permit#t: file#5228
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)if known 1 6 oz
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) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ® Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slum ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material.elected abure,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation well mix - 4 yards
❑Aquifer Storage and Recovery ❑Salinity Barrier --
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7,, Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Coolin Return ❑Other(explain under7 removed plumbing; dE:watered via tremie pipe;
chlorinated; filled with well mix to top of casing.
4.Date well(s)abandoned: 1/3/24
5a.Well location:
CEDAR GROVE MHP 11, LLC
Facility/Owner Name Facility ID#(if applicable) tl.Certification:
675 FLYNNWOOD DR., KERNERSVILLE, NC 27284 Q. 1/4/24
Physical Address,City,and Zip Signatu f Certified Well Contractor or Well Owner Date
Forsyth 6887-83-3280
By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lationg is sufficicm) 9.Site diagram or additional well details:
36.143332 N -80.052977 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 record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction abandonment,you can submit one form.
109. 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: 410 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6-5/8 (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 60 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft,) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also s tape tit�py"'tl� slitltiri 30 days of completion
of well abandonment t eallr ter �thVtl �kck of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
FEB 1 2 2024
6g.Screen length(if known): (ft.) k16eIXA4W'1?rn *@W;r`2 UO.
0WQi5-DG
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22.2016