Forsyth_Well Abandonment_20240910 (5)

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 1 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): 294 (gal.)
Venable Brothers Well Const., Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium Hypochlorite
7c.Type of disinfectant used: Calcium
2.Well Construction Permit Al:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)tf nown
7d.Amount of disinfectant used: OZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing mate ' Isiased{cheek all tottttp Iy):
❑Agricultural ❑MunicipaliPublic ❑Neat Cement�rtlul :`,L_l ••% �--�Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ■Residential Water Supply(single) ❑ Sand Cement Grout a Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) III Concrete Grout S E P 1 0202 4❑Drill Cuttings
OIrrigation ❑ Specialty Grout �,, jilifvel
Non-Water Supply Well: ❑Bentonite SI
�� '3G ❑ er(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GrotmdwaterRemediation well mix - 1.25 yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief descriplion of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
(Heating/Cooling❑Geothermal Return ❑Other(explain under 7 ) removed plumbing; dewatered via tremie pipe;
chlorinated; filled with well mix to surface
4.Date well(s)abandoned: 8/6/2024
is.Well location:
KEYSTONE GROUP
Facility/Owner Name Facility ID#(ifapplicable) S.Certification:
4540 EBERT RD WINSTON SALEM NC 27127 Q. �y 4 8/6/2024
Physical Address,City,and Zip Signat f Certified Well Contractor or Well Owner Date
Forsyth 6812-35-6868
By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 01C.0100 or 1C.0200 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/long is sufficient) 9.Site diagram or additional well details:
36.012857 N -80.306008 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
6s.Well IDN: abandonment to the following:
Division of Water Resources,Information Processing Unit,
eb.Total"ell depth: 206 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iuiection 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: 10 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10e.For Water Sunoly&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)
Fonn G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016