HomeMy WebLinkAboutStokes_Well Abandonment_20230706 WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Sam Hooker
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:
N/A 117+/-
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
N/A FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Calcium Hypochlorite
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 2 lbs.
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 0 Neat Cement Grout 0 Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) 'Residential Water Supply(single) 0 Sand Cement Grout I Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 4+yards red clay
[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 Backfilled with red clay
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 7' -A `' r `�t
Removed pump and piping ` -�w'' -i i ;`
4.Date well(s)abandoned: 5/25/2023 J 1J! 0 C 2023
5a.Well location: I nforn1.-Af.i..7.71 "�.�.c;,�r:-. l,r,i
Sam Hooker N/A
Facility/Owner Name • Facility 11311(if applicable) 8.Certification:
0 Moore Road, King, NC 27021 61W-23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Stokes 17405
By signing this form, I 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 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:
N921086,94 N E1602139.39 , 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 records)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. lOa For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: N/A abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 34 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
Eta Borehole diameter: 24 (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: 5 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): unknown (ft.) 10c.For Water Sunnlv&Injection 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
6£Inner casing/tubing length(if known): unknown (f£) 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
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Sam Hooker 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
N/A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 447+/
N/A FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium Hypoclorite
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UDC,County,State,Variance,etc.)if known 3 lbs.
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 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout "[Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
- - Non-Water Supply Well: - - 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 5+yards red clay
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Backfilled with red clay
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
No pump or piping :4 ' ;�
4.Date well(s)abandoned: (�
5/25/2023 ,k z 'a,. a -
11
Sa Well location: JUL ( (: LOLJ
Sam Hooker N/A
c.. ei-. �t .ter-';: ✓ {...
Facility/Owner Name Facility ID/I(if applicable) 8.Certification:
0 Moore Road, King, NC 27021 6 �l
Physical Address,City,and Zip Si ofCCeerd�Well Contractor or Well Owner Date
Stokes 17405
By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I SA 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:
N921133.10 N E1602273.19 �, 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(S1 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. l0a For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: N/A abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 42 (ft)
_ 10b.For Injection 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:
6d.Water level below ground surface: 19 (f`) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): unknown (ft) lOc For Water Suaaly&Injection 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
6L Inner casing/tubing length(if known): unknown (ft) abandoned.
6g.Screen length(f known): unknown (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016