Forsyth_Well Abandonment_20240910 (8)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
J. Michael Venable 7s.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
NCWC-2079-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 310_(gal.)
Venable Brothers Well Const., Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium Hpochlorite
7c.Type of disinfectant used: Calcium
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,6ariance,etc)ifitnown 10 oZ
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check pll piat-Voy):
❑Agricultural ❑Municipal/Public ❑Neat Cement> oft[_ S` f "entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑Sand Cemen bul- A S Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ■Concrete Grout SE p 1 0 j24 ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout a fr^ tvel
Non-Water Supple Well: ❑Bentonite ❑Other(explain under 7g)
.-
❑Monitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials axed:
❑Aquifer Recharge ❑Groundwater Remediation well mix-4 yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage clean clay-1 yard
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heatin Coolin Return) ❑Other(explain under7 ) removed plumbing; dewatered;
chlorinated; removed top 3 ft of tile;
a.Date wells)abandoned: 8/1/2024 filled with well mix to form plug;
9;
5a.Well location: topped with clean clay
Octavia T. Blackburn
Facility/Owner Name Facility lD#(ifapplicable) S.(crtification:
245 Carter Circle, Winston Salem, NC 27106 g. 8/1/2024
Physical Address,City,and Zip Sis.0c of Certified Well Contractor or Well Owner Date
Forsyth 6816-35-7898
By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Idemification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0100 Well Construction Standards
and that a copy of this record has been provided to the well owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.121987 N -80.308120 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 Infection 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: 23 (It,) 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
addresses)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 G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016