Forsyth_Well Abandonment_20240910 (4)

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 I GW-30 is needed. Indicate TOTAL NUMBER of
N CWC-2079-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 229 (gal.)
Venable Brothers Well Const.r Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
7c.Type otdisinfectant used:.Calcium
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)tfbtown
7d.:lmount of disinfectant used: OZ
3.Well use(check well use): [[� _.
Water Supply Well: 7e.Sealing materLals twadrelleskell tliatlap�r
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ■Residential Water Supply(single) El Sand Cement Grout sE 1 O �2CM Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ■Concrete Grout �,,_, W Cuttings
❑Irri tion ❑ Specialty Groutt f Z r •: �
p ty D'AiGf1!4DG El Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation well mix - 7.5 yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage clean clay - 1 yard
❑Experimental Technology ❑Subsidence Control 7
❑Geothermal(Closed Loop) ❑Tracer Pruride a brief description of the abandonment procedure:
removed plumbing; dewatered;
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7 )
chlorinated; removed top 3 ft of tile;
a.Date well(s)abandoned: 8/29/2024 filled with well mix to form plug;
9;
Sa.R ell location: topped with clean clay
WESTCAR PROPERTIES.LLC/FRANK HERNANDEZ
Facility/OwnerName Facility ID#(ifapplicable) 8.(ertification:
7113 HUNTING BROOK CT., WALKERTOWN, NC Q. -)')� 8/30/2024
Physical Address,City,and Zip Si of Certified Well Contractor or Well Owner Date
Forsyth 6869-74-1021
By signing this form, !hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0100 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.
(ifwell field,one lat/bng is sufficient) 9.Site diagram or additional well details:
36.201354 N -80.128190 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 constructionbbandonment,you can submit one.form.
10a. For All Wells: Submit this form within 30 days of completion of well
6s.Well ID#• abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 59 (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: 24 (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: 45 (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 Suooly&Infection 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
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016