Stokes_Well Abandonment_20230724 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
BRIAN THOMAS 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-whterj .supply ' wells ONLY with the .same
construction'ahandonment,you can submit one form.
A - 2581 18.0
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s):'
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
Litt all applicable well construction permits(i.e.County,State, Variance,etc.)tfknown 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(Heaiing/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 0 Other(explain under 7g)
OMonitoring- ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 25;25.GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
. ❑Aquifer Test ❑StormwaterDrainage
❑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) ❑Other(explain under 7g)
4.Date well(s)abandoned: 05/11/23
Sa.Well location: s
BELEWS CREEK STEAM STATION ,,
Facility/Owner Name Facility ID#(ifapplicable) 8•Certification: r.
3195 PINE HALL ROAD BELEWS CREEK 27009 eWx °5,'---,;07/18/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
STOKES By signing this form, 1 hereby certify that the ivell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance ivith I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
360 16' 52.32" 800 03' 33.78" 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 records)if available. For multiple injection or non-n•ater supply
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
PMW-7BR abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 155.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection 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
6e.Borehole diameter: (in.) abandonment to the following:
44.79 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 Sunaly&Injection 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
where abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): 10.0.
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013