Stokes_Well Abandonment_20240731

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis 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
NCWC 351O-A wel Is abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): �1'2 (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: NA
List all applicable well construction permits(i.e.IIIC,County Stale,Variance,etc.)Ifknown
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 @ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial _ ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation `'! r ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
@Monitoring 31AHry
Injection Well: 71. I or each material selected above,provide amount of materials used:
❑Aquifer Recharge (f�s;;rk rr,; I'!!C 6asirukN llWemediation —60 Ibs Bentonite Chips
❑Aquifer Storage and Recovery p'KC;31_'i4nity Barrier --
-10 Ibs Neat Cement Grout
❑Aquifer Test ❑Stormvvater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) Concrete pad and manway were removed from well.
Bentonite was placed in one foot lifts and hydrated
4.Date well(s)abandoned: 5/28/2024
until one foot from top of casing. Remaining space
5a.Well location: was capped with grout to-6"above PVC.Remaining was covered with soil.
Ferrelli Property 0-0-47128
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
1238 NC Highway 704 East,Lawsonville, North Carolina, 27022 � 3 July 16, 2024
Phvsical Address,City,and Zip Signature ofCertified Wel ontractor or Well Owner Date
Stokes 6041242387.000
By signing this form, 1 hereby certify that the well(s)was(were)abandoned in
County Parcel Identificaw,n\o.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field.one lat/long is sufficient) 9.Site diagram or additional well details:
36.5370210 N -80.216601° 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 ifnecessary.
(ONSIRt( I ION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
, tlacinrrl/roiutrucaanrecord(s)iijarailabte. For multiple injection ornon-iratersupplywells
ONLY with the same construction abandonment,you can submit one firm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 54.00 (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: 2.00 (irl.) 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: 46.77 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
NA (ft.) 10c.For Water Supply&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 county health department of the county where
6E Inner casing/tubing length(if known): NA (ft) abandoned.
6g.Screen length(if known): 34-54 (ft.)
Form GW-30 North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 2-22-2016