Stokes_Well Abandonment_20230724

WELL-ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
B RIAN THOMAS 7a:Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water! supply wells ONLY uvith the same
construction'ahatdmvnent,you can submit one form.
A - 2581 12.5
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.C'otmty,State,Variance,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e..Sealing materials used(check all that apply):
❑Agricultural 17Municipal/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 ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 21 Other(explain under 7g)
OMonitoring:: ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 22.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrie'r
❑Aquifer Test' ❑Stormwater Drainage
❑Experimental Technology: ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop). ❑Tracer ABANDONED VIA TREMIE PIPE WITH BAROID AQUAGUARD
❑Geothermal(Heating/Cooling Return) 00ther(explain under 7g) & §ram
•,.,r
4.Date well(s)abandoned: .' 05/1 1/23 J I IL 2 4 2023
Sa.Well location: ItT`Grr13Ji� Unk
BELEWS CREEK STEAM STATION
Facility/Owner Name Facility ID#(if applicable) &Certification:
3195 PINE HALL ROAD BELEWS CREEK 27009 �"'"
07/18/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
STOKES By signing this form, 1 hereby cettrfy that lire ivell(s) was (1vere) abandoned in
County Parcel Identification No.(PIN) accordance ivith 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 dr decimal degrees:
(if well field,one lat(long is sufficient) 9.Site diagram or additional well details:
360 16' 52.22" N 800 03' 33.84" 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 recorel(s)if available. For multiple injection or'non-water supply
wells ONLY with the same cotrsrrmctioniabmvdonwent,you can submit one.lorin. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
PMW-4BR abandonment to the following:
Division of Water Quality,Information Processing Unit,
66.Total well depth: (ft.)
140.0 1611 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
2.0 above, also submit one copy-of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
61.67 Division of Water Quality,Underground Injection Control Program,
6d:Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft. 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
6E Inner casing/tubing length.(if known): (ft.) where abandoned.
6g.Screen length(if known): 0'� (ft.)
I I
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality; Revised March 2013
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