Forsyth_Well Abandonment_20240514 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
AARO N GIBBONS (OWNER) 7a.For Geoprobe/DPT or Close d-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/A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 30 (gal.)
N/A FOR WATER SUPPLY WELLS ONLY:
Company Name 70% HTH CHLORINE
2.Well Construction Permit#:
FILE#397607 7c.Type of disinfectant used:
List all applicable tivell construction permits(i.e. UIC,County,State, Variance,etc)ifknotivn 416'.
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) CResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) S Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
-NoiL-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 El Groundwater Remediation can 11 401Uy
� QQ
❑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 �/
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) t'�j`a/ NSs- cr- 0.t P
r
5/1/2024 ("d4z cenezie_ s ee.
4.Date well(s)abandoned: conar c P
� cr;-fit►--5'ts,�c��c� COaI�
5a.Well location: L:•t
AARON GIBBONS ��� MAY 1 % 2024
Facility/Owner Name Facility ID#(if applicable) 8�Certfflication:
4720 KINNAMON RD WINSTON SALEM NC 27103 ►�`� {` r^t^..
Physical Address,City,and Zip Signature of Certified W 11 Contractor or Well Owner` Dat
FORSYTH 5893-45-5760 By signing this form, I hereby cert6 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 lit/long is sufficient) 9.Site diagram or additional well details:
36.038644 _�_80.371024 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.
- 4
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply 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: eQ� (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: cR (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 13 (ft.) Raleigh,NC 27699-1636
1636 Mail Servicee Center,
6e.Outer casing length(if known): (g,) 10c.For Water Sunnly&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 Resource -22-2016 Revised 2
I .

tooHOArs FORSYTH COUNTY HEALTH DEPARTMENT
Q� Division of Environmental Health
P.O. Box 686, Winston-Salem, NC 27102 t0a n*569'a 45—546o
336-703-3225
File Number 39RCO:�
Lot a013 Block'4c233 _
WELL ABANDONMENT RECORD
Contractor OUNj'-, S- ' , Registration No. n
Well Location: (Show a sketch of the site at the right on this form)
Bo. 34joaq
Owner A ron s
Site Address 4 4 a0 !<,n n c-^a1% r!61 SITE DIAGRAM
"
Topography: draw, slope, hilltop, valley, fl
Use of Well 590 Date
Total Depth Diameter 90"
Casing Removed:
Feet Diameter
J. go„
Sealing Material:
Neat Cement Sand Cement
bags cement bags cement Ric/
gals water yds sand `Y
gals water
Other:
Type material r°nne, oaopll rnbe �Z 5'
Amount
Explain method of emplacement of material: L J
lj
I do hereby certify that this well abandonment record is
true and ex ct.
�.
Signature—Contractor/Owner D ate
Sig ture— .S. D to
COPIES:WHITE—HEALTH DEPT. / YELLOW—CONTRACTOR / PINK—HOMEOWNER Rev&Reset FCPS 1-22-2014