Forsyth_Well Abandonment_20240507

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Ronald F. Barron I
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
2091-A wells abandoned:WA I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): DrY (gal.)
I.
Piedmont Industrial Services FOR WATER SUPPLY WELLSONLY:
Company Name
2.Well Construction Permit#:
409757 7c.Type of disinfectant used: A./4
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)([known , / ��7d.Amount of disinfectant used: i
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials ec (check all that apply):
❑Agricultural eMunicipal/Public ❑ Neat Cement Grout(' ; ,iii,.r t l l,Bermo'i to Chips or Pellets
._."
❑Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ❑ Sand Cement Grout . j ❑ Dry C ay
❑lndustrial/Commercial ❑Residential Water Supply(shared) • Concrete Grout MAY U it •[ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravelt
Non-Water Supply Well: ❑Bentonite Slurry � :Prr�6"i4gtlf t explain under 7g)
❑Monitoring ❑Recovery j e tt
Injection Well: 7f.For each material selected above,provide amount of materials used:
DAquifer Recharge ❑GroundwaterRemediation 1 Yard Concrete
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage II
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Fill 20"well with 1 yd concrete to 3' below ground surface
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Remove 3"soil and a 1'radius around 20"well and cap with
4.Date well(s)abandoned: 5-1-24 1'concrete and fill to ground surface with remaining soil.
5a.Well location:
Todd Hinson N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
6410 Harperwood Trail �� 0 u- 5-1-24
Physical Address,City,and Zip • Signature of Certified Well Contractor or Well Owner Date
Forsyth 5884-26-1782 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 lat/long is sufficient)
9.Site diagram or additional well details:
36.068614 N 80.413378 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.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: N/A abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
1
10b.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: DrY (ft.) Division of Water Resources,UI derground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
Unknown 10c.For Water Supply&Iniectionl Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county Ihealth department of the county where
6f.Inner casing/tubing length(if known): Unknown(ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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WELL ABANDONMENT PERMIT . •�¢' 4N, FILE# 409757
FORSYTH COUNTY DEPT.OF PUBLIC HEALTH p� ,•; ... PIN# 5884-26-1782
DIVISION OF ENVIRONMENTAL HEALTH ,�^j�,�,1k-.:= a LOT: 71C BLOCK: 4405
.� E�,rl1'S /
799 NORTH HIGHLAND AVENUE
WINSTON SALEM NC 27102
336-703-3225 WELL: 1 OF.
OWNER/APPLICANT: TODD HINSON
SITE ADDRESS: 6410 HARPERWOOD TRAIL CLEMMONS NC 27012
Well Coordinates: 36.068614 N: W; 80.413378
WELL TYPE: BORED /HAND DUG WELL DIAMETER: 12
(inches)TOTAL DEPTH: (feet)
Static Water Level: DRY (feet) .
PERMIT CONDITIONS:
O Plumbing present in well to be removed before abandonment
0 Water in large diameter wells shall be pumped out prior to abandonment
LARGE CONCRETE CAP ON TOP OF THE WELL, WILL NEED TO BE REMOVED TO COMPLETE
INSPECTION, PACK WELL WITH CLEAN CLAY OR FILL WITH WELL MIX ICONCRETE, DIG
DOWN 3FT AND POUR 6"THICK CONCRETE PLUG OVER THE WELL. .
EHS: MIKE MERRELL II REHS ISSUED DATE: 3.19.24
*CERTIFIED WELL DRILLER REQUIRED TO BE ONSITE FOR WELL ABANDONMENT,WELL SHALL BE ABANDONED PER THE
15A NCAC 02C.0100 RULES,SEE CONDITIONS ABOVE FOR SPECIFIC ABANDONMENT REQUIREMENTS.
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WELL ABANDONMENT RECORD For Internal Use ONLY: !
I
1
1.Well Contractor Information: WELL ABANDONMENT DETAILS,
I
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-2079-A wells abandoned: 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 320 (gal.)
I.
Venable Brothers Well Const., Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H t-lochlorite
7c.Type of disinfectant used: , YP
2.Well Construction Permit#: File#-411281
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 10 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 0 Neat Cement Grout 0 Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) •Residential Water Supply(single) ❑Sand CemengjP,ri=,odt :` ; :.! J •".I ry Clay
❑Industrial/Commercial ' ❑Residential Water Supply(shared) • Concrete Grout<:`..---S-1 L.T•i +•�? 1.„.. 1 rill Cuttings
❑Irrigation 0 Specialty Grout MAY V 6 2024 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery ern . y *"e3 ;�n-.�,.r;-,. t *
.>� r .
Injection Well: 7f.For each material s ie ted.a)iove,pr'orr �a7nount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation well mix- 1 yard
i
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage clean clay- 24 yards
❑Experimental Technology 0 Subsidence Control i'
7g.Provide a brief description of the abandonment procedure:
DGeothermal(Closed Loop) ❑Tracer removed plumbing; dewatered;
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
chlorinated; filled with clean clay packed in 5 ft lifts;
4.Date well(s)abandoned: 3/23/2024 dig down & remove 3 ft;of well below grade;
5a.Well location: poured 6" concrete plug'.and topped with clean clay.
Susan M. Smith
I
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
3190 Old Salisbury Rd., Winston Salem, NC . W.A. 1" .Q.6& 4/23/2024
Physical Address,City,and Zip Sig s of Certified Well Contractor or Well Owner Date
Forsyth 6822-41-3390
By signing this form,I hereby certt'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 lat/long is sufficient) 9.Site diagram or additional well details:
35.999948 N -80.269445 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 fonn.
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,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 40 (ft)
10b.For Injection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 42 (in.)
abandonment to the following: i,
I '
6d.Water level below ground surface: 34 (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
t
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 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

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS j '
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-2079-A wells abandoned: I
!
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <100 (gal.)
Venable Brothers Well Const., Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
2.Well Construction Permit#:
FILE #79932 7c.Typeofdisinfectantused: YP
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: n/a
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): .
DAgricultural ❑Municipal/Public 0 Neat Cement Grout. ..._.. . ., _,.. r r7_,BEntonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) •Residential Water Supply(single) 0 Sand Cement Gr u., ; t. .r,„,y ,• 1"D )la
� €/ g PP Y) PP Y( g ) 9uk,� _ L. 4.. ry� Y
❑Industrial/Commercial ❑Residential Water Supply(shared) •Concrete Grout 1 ` ' Drill Cuttings
❑Irrigation 0 Specialty Grout MAY i) 1 202'b Gravel
Non-Water Supply Well: 0 Bentonite Slurry Ohe (explain under 7g)
❑Monitoring ❑Recovery I
‹.:Pr '`''P`it?tr� :r,' F.
Injection Well: 7f.For each material selecptsI3de, rovide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation well mix- 1 yard I,
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage clean clay-24 yards
❑Experimental Technology ❑Subsidence Control ' 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer j:
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) removed plumbing; removed top 3 ft of tile;
filled well with clean clay in 5 ft lifts; packed;
4.Date well(s)abandoned: 3/26/24 poured cement plug; topped with clean clay. • •
5a.Well location:
ROBERT&BETSEY HENDRIX ,
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
6640 DORAL DR., TOBACCOVILLE, NC 27050 7y i/ 3/26/24
Physical Address,City,and Zip Si a of Certified Well Contractor or Well Owner Date
Forsyth 5990-75-9201
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 lat/long is sufficient) 9.Site diagram or additional well details:
36.229521 N -80.362955 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.
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 42 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 60 (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: 41 (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 submit one copy bf 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
. i ,

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
I' ,
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-2079-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of wateremainiug in well(s): 998 (gal.) •
Venable Brothers Well Const., Inc. �
FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
7c.Type of disinfectant used: • YP
2.Well Construction Permit#: File#- 280018
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: 3O
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipalPublic 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) •Residential Water Supply(single) 0 Sand Cement Grout i 0 Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) •Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring DRecovery I,
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation well mix- 6 I' •
❑Aquifer Storage and Recovery 0 Salinity Barrier I
❑Aquifer Test ❑Stormwater Drainage I,
DExperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
0 Geothermal(Closed Loop) OTracer removed plumbing; chlorinated; dewatered via
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
tremie; fill to surface with well mix
4.Date well(s)abandoned: 3/4/2024
5a.Well location: II
: V i. t,..1 ti..,t`. V' C.: ..f
RSPD-Riverwalk,LLC/RS Parker Homes r
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
MAY i 2024
4050 Foxpark Dr., Clemmons, NC 27012 . `,1 1/ � 1IniN7fk'f71 3, /57m:2 UV:t
Physical Address,City,and Zip Signal of Certified Well Contractor or;Well Owner D'-Uate': "3
Forsyth 5881-67-4909 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 Mt/long is sufficient) 9.Site diagram or additional.well details:
• 35.987360 N -80.408228 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.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 2 abandonment to the following: C
I
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 705 (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 (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: 40 (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 submit one'copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): (ft) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality 7 Division of Water Resources Revised 2-22-2016

•
i
•
WELL ABANDONMENT RECORD For Internal Use ONLY: 1
I
1.Well Contractor Information: WELL ABANDONMENT DETAII:S
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-2079-A
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of Ovate I remaining in well(s): 220 (gal.)
Venable Brothers Well Const., Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H YPpochlorite
7c.Type of disinfectant used:
2.Well Construction Permit#: File#-408157
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.)if known
7d.Amount of disinfectant used
7
3.Well use(check well use): .
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) •Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) •Concrete Grout 0 Drill Cuttings
❑Irrigation - 0 Specialty Grout 1 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery ,
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation well mix-2 yards 1
❑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) OTracer I
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) removed plumbing; chlorinated; dewatered via
tremie; fill to surface with well mix �__
3/4/2024 1 ►`,_.-. 7 I
4.Date well(s)abandoned: i 'i,ti...IL,'L.i V' ' .LLf:
5a.Well location: MAY t) '+ 2024
RSPD-Riverwalk,LLC/RS Parker Homes I
Facility/Owner Name Facility ID#(if applicable) 8.Certification: 1, Info;F,;s'CO .i'm2,.1.fni'':g Ui
4025 Foxpark Dr., Clemmons, NC 27012 1� .e� L3/5/2024
Physical Address,City,and Zip Signal of Certified Well Contractor orWell Owner Date
Forsyth , 5881-37-7577
By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA 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 lat/long is sufficient) 9.Site diagram or additional well details:
35.987862 N -80.407952 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 records)lfavailable.For multiple Injection ornon-Hater supply wells
ONLY with the sante construction/abandonment,you can submit one form.
10a. For All Wells: Submit this,;form within 30 days of completion of well
6a.Well ID#: 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 195 (ft) ' 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: 1
6d.Water level below ground surface: 48 (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&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.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016