Forsyth_Well Abandonment_20240401

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information:. WELL ABANDONMENT DETAILS
K. Brandon Moore 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
wells abandoned:
2957-A i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Paragon Environmental Consultants,.Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
2.Well Construction Permit#:
409084 7c.Type of disinfectant used: yp
List all applicable ivell construction permits(i.e.UIC County,State,Variance,etc.)iflrnown 13 oz.
7d.Amount of disinfectant used:
3.Well use(check well use):
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Water Supply Well: 7e.Sealing materials used(check'all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cdoling Supply) RResideritial Water Supply(single) ❑ Sand Cement Grout a Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout I ❑Drill Cuttings
❑Irri atiou• ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Dry Clay(from on-site) 17 cubic yards
❑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 Placed and compacted clay soil from on-site
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
into well void and;filled to land surface.
4.Date well(s)abandoned: 3/21/24
5a.Well locati6n: ' 't
NC.DOT N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification: — 2024
4356 Old Belews Creek Rd. lR5,-`'„ ,-� .'
,;r .
� �c�,: 3/21/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Winston-Salem, NC 27101 BI. 91 B Lot 3257
By signing this form, 1 hereby certify that the well(s) was(were) abandoned in
County 1�� I , Parcel Identification No.(PIN) accordance with ISA NCAC 02C:0100 or 2C.0200 Well Construction Standards
1 -J 1 ��--Fjr^` and that a copy of this record has been provided to the well owner.
Sb.Latitude and longi e n egrees/minutes/seconds or decimal degrees:
(ifwell field,orie lat/long is ufficient) 9.Site diagram or additional well details:
36.129711 N 80.175590 `ir 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.
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CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells --
ONLYwirh 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#• SW:1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 32 at) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
48-60 above,also submit one copy of this form within 30 days of completion of well
6c Borehole diameter: ( ) "' abandonment to the following:
6d.Water level below ground surface• 30 (ft) Division of Water Resources Underground Injection Control Program,
1636 Mail Service iCenter,Raleigh,NC 27699-1636
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N/A 10c.For Water SUDDIV&Iniection Wells: In addition to sending the form to the
6e Outer casing length(if known): (ft.) 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
611 Inner casing/tubing length(if known): N/A (ft) abandoned.
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6g.Screen length(if known):.N/A (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resourcb s Revised 2-22-2016