Forsyth_Well Abandonment_20240325

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
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Todd Scott 7a.For Geoprobe/DPT or Closed4Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GWr 3,0 is needed. Indicate TOTAL NUMBER of
3335-A wells abandoned: ;
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
' Dogwood Industrial Service Company FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Pool chlorine/shock
2.Well Construction Permit#: 405067
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.)if known '2 lbs.
7d.Amount of disinfectant used::
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check an that apply):
['Agricultural ❑Municipal/Public 0 Neat Cement Grout I 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) lResidential Water Supply(single) 0 Sand Cement Grout I ; ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) • Concrete Grout 0 Drill Cuttings
❑Irrigation - CI Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ['Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
['Aquifer Recharge ❑Groundwater Remediation 1 .5 yards
0 Aquifer Storage and Recovery ['Salinity Barrier
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❑Aquifer Test ❑Stonnwater Drainage
['Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer i
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) tremied ash free well;abandonment mix from
the bottom of the well to the top
4.Date well(s)abandoned: 3/1 2/2024 1'
5a.Well location: '-
Brian Edwards 7:
Facility/Owner Name Facility ID#(if applicable) 8.Certification: /
157 Harmon Mill Road - ' /AWA, 1 (�/f� Z2-/
Physical Address,City,and Zip Sign ure of ertified ' e IF tor Or Well Owner Date
Forsyth
By signin: I s form, 1 tereby cerli)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 latltong is sufficient) 9.Site diagram or additional well details:
36.107520 N 80.115582 W You may use the back of this page Ito provide additional well site details or well
abandonment details. You may alsoi 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 I
ONLY with the same construction/abandonment,you can submit o orm.
tom--,,,,,,.„„ 10a. For All Wells: Submit this'form within 30 days of completion of well
6a.Well ID#: r.,
t? .f i"'a donment to the following: I
C MAR2Division of Water Resources,Information Processing Unit,
6b.Total well depth: 175 (ft) �, 2024 1617 Mail Service Center,Raleigh,NC 27699-1617
lft '
£ T:, c;,a" �;y, it 0 .For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.)
6 G'c�JCti3'3r�, ab,.ove,also submit one copy of this form within 30 days of completion of well abandonment to the following: 1
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6d.Water level below ground surface:
10 (ft.) Division of Water Resources;Underground Injection Control Program,
1636 Mail Service,Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): unknown (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit once copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
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6f.Inner casing/tubing length(if known): unknown (ft.) abandoned. !
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6g.Screen length(if known): unknown (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016