Stokes_Well Abandonment_ (9)

WELL ABANDONMENT RECORD For Internal Use ONLY: r
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Timothy D._Leatherman 7a.For Geoprobe/DPT or Closed-Ii o I p 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
2888A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water riemaining in well(s): (gal.)
Pyramid Environmental and Engineering P.C. -
, FOR WATER SUPPLY WELLS ONLY: �
V , '
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: NA 1\� 'n
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknosm j A � 202,3
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 R Neat Cement Grout N Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustrial/Commereial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
RMonitoting ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 50 Pounds Bentonite ;, 5 Pounds Portland
❑Aquifer Storage and Recovery ❑Salinity Battier
❑Aquifer Test ❑StormwaterDrainage
Chips/Pellets ;. Grout Cement
❑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) Slow pour Bentonite and trimie pipe/slow pour
P grout cement.
4.Date well(s)abandoner ,�0 1M
5a.Well location:
Stokes Schools- Bus Garage NA
Facility/Owner Name Facility lD#(if applicable) S.Certification:
3160 NC Hwy 65 W., Germanton, NC r
Physical Address,City,and Zip Signature of CerWied Well Contractor or Well Owner Date
Stokes 6941085047
By signing this form,I hereby certify that the we[[(sJ 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 lat/long is sufficient) 9.Site diagram or additional well details:
36.266196 N -80.219645 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also'atfach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.FormuItiple injection or non-water supply wells
ONLY with the same construchon/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• M W-1 1 abandonment to the following: 1
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 19 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8(2-Inch dia)(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: 4.37 (ft.) Division of Water Resources,Und 11 erground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known):
NA (ft.) IOc.For Water Suaaly&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 courity,health department of the county where
611 Inner casing/tubing length(if known): 9 (ft) abandoned. I;
1
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016