Stokes_Well Abandonment_ (7)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Timothy D. Leatherman 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 GW30i is needed. Indicate TOTAL NUMBER of
2888A wells abandoned: i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Ir
Pyramid Environmental and Engineering, P.C. FOR WATER SUPPLYWELLS!ONLY:
Company Name ;, <
7c.Type of disinfectant used:
2.Well Construction Permit#: NA
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown i. A 11� f n
7d.Amount of disinfectant used: /i
3.Well use(check well use): In i, •l �r�
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentonite Chips orT'ellels
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
'❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 45 Pounds Bentonite 5 Pounds Portland
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑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
grout cement.
4.Date wells)abandoned
5a.Well location:
Stokes County Bus Garage NA
Facility/Owner Name Facility ID#(ifapplicable) S.Certification:
3160 NC Hwy 65 W., Germanton, NC i
Physical Address,City,and Zip Signature of Cert :ed Well Contractor or Well Owner Date
Stokes 6941085047
By signing this form,I hereby certij�that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy ofthis record has been provided to the well owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 9.Site diagram or additional well;details:
36.266059 N -80.219623 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.Formultiple injection ornon-watersupply wells
ONLY with the same construction/abandonment you can submit one form. j'
10a. For All Wells: Submit this,form within 30 days of completion of well
M W-9 abandonment to the following:
6a.Well ID#: '
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 18 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
8 (2-inch dia.) above, also submit one copy of this form within 30 days of completion of well
r:6c.Borehole diamete (in.)
abandonment to the following: !'
i
i '
6d.Water level below ground surface: 4.37 (fG) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
NA 10c.For Water Supply&Iniectio�Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
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): 8 (ft.) abandoned.
6g.Screen length Cif known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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