Forsyth_Well Abandonment_20241022 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.7Contractor I rmation: /� (] � ) WELL ABANDONMENT DETAILS
0 U\( C_ 6 Ap,%Q (— 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
wells abandoned:
NC Well Co tractor Cccrtifica'on Numbcr1 7b.Approximate volume of water remaining in well(s): (gal.)
Co
"\k 6% 0 q Z;'J C. FOR WATER SUPPLY WELLS ONLY-.'
Company Name V
7c.Type of disinfectant used: 1 k�
2.Well Construction Permit#:
List all applicable Hell construction permits(i.e.UIC,County,State,Variance,etc.)ijknown Cr7
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply);__1
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout""` ''` > ❑ Bentpniie Chips or Pellets
❑Geothermal(Heating/Cooling Supply) *esidential Water Supply(single) *and Cement Grout ` ''" '' ❑ Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout O T �� `02144,U Cuttings
❑Irri ation ❑Specialty Grout 1 ❑Gravel
Non-Water Supply Well: a-r�, ' ' t�h1
❑Bentonite Slurry lr.`.r.-;, 13'Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above, rovide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑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 `
0Geothermal(Heating(Cooling Return) El Other(explain under 7g)
4.Date well(s)abandoned: / © ✓
l CbNc, cIAS►� �►s>►s�►e�uy\'��1 �
5a.Well location LdNL• CA,p1 �(N� 9�lllp Gol k
\ e c11L�\p 5�� L
Facilit/Owner Name Facility IDI(if applicable). 8.Ce � cation: IJ y
RA
Physical AddressCity,and Zip �l oq Signature of Certified Well Contractor or Well Owner Date
ff �1 By signing this form, 1 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 pr vided 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:, : .
N W You may use the back of this page to provide additional well site details'ar well,
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach wellconuructionrecord(s)ifmailable.Formulriple.injection ornon-rvatersupplrwells
ONLY,vi(h[he same constnrction/abandonment,you can submit onejornr. 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: /' (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
tl 10b.For Infection Wells: In addition to sending the form to the address in IOn,
6c.Borehole.diameter: o (in.) above,also submit one copy of this form within 30 days of completion.of.,vell
abandonment to the following:
6d.Water level below ground surface: (ft.) Division of Water Resources,Undergro`u'nd Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636,
o`e.Outer casing length(if known). (ft.) 10c.For Water Supply&Injection Wells:'hi dddition to sending the form to the
address(is)above;also submit one copy of this'forrri within 30 days of completion
of well abandonment to the county health, department of the county where
`f 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
WELL ABANDONMENT RECORD For Internal Use ONLY:
e
1 ,
1.Well Contractor Information: WELL ABANDONMENT DETAII:S
K. Brandon Moore 7a.For Geoprol�e/DPT or Closed)-LI op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 G W-30 is needed. Indicate TOTAL NUMBER of
2957-A wells abandoned: f
Unknown
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY: '
Company Name Calcium H ochlorite
7c.Type of disinfectant used: yp
2.Well Construction Permit#l: W-24-67
List all applicable we/1 construction pernifts(i.e.UIC,('aunty,&are,Variance,erc.)#'known 13 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 ❑ Neat Cement Grout _ ❑iBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ❑ Sand Cement Grout
❑industrial/Commercial ❑Residential Water Supply(shared) 9 Concrete Grout ❑ Drill Cuttings
r. ,(�
❑lrri ation ❑ Specialty Grout OCT ,,, d Q�ar vel
Non-Water Supply Well: '❑ Bentonite Slurry ❑Other,(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected a6v"e;piovid'e'amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete mix 7.5 cubic yards
❑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 Poured concrete directly into well casing
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) .
and filled to within'3 feet of surface where
a.Date well(s)abandoned: 10/2/24 18" thick concrete-plug was installed on top.
5a.Well location:
James Potts N/A
Facility/Owner Name Facility ID9(if applicable) 8.Certification:
2080 Welfare Rd. ,/ 99, 2�15�-,9 10/2/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Winston-Salem, NC 27127 0300100000018
By signing this•form, I hereby ceitiify that the well(s) was (were) abandoned in
County Lfi�S/� Parcel Identification No.(PIN) accordance with 15A NCAC 02C.QI00 or 2C.0200 Well Consiniction Standards-
and that a copy ojlhis record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9-Sitc diagram or additional well details:
35.996297 N 80.316211 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 wel/cosine•Uon record(s)ijavailahle.4-16r multiple hi ecionornon-warw•supply wells .. _
ON/,Y with flit,some cruxrrrncviomahmidonn,enr,you can submit ane,farm. 10a. For All Wells- Submit this form within 30 days of completion of well
6a.Well IDN: SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 57 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
i•
10b.For Iniection 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: 1
I
6d.Water level below ground'surface- Unknown (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I"
6e.Outer casing length(if known): Unknown (ft) loc.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one dopy of this form within 30 days of completion
of well abandonment to the cougty,�health 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