Stokes_Well Abandonment_20230724 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
J. Michael Venable : 7a.For Geoprobe/DPTorClosed-L,00p Geothermal Wells having die same
Well Contractor Name(or well owner personally abandoning well on his/ber property) well construction/depth,only 1 GW-30'is heeded. Indicate TOTAL NUMBER of
wells abandoned:
NCWC-2079-A
NC Wen ContructorCertification Number 7b.Approximate volume of water remaining in well(s): (gat.)
Venable Brothers Well Const., Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c,Type of disinfectant used: Calcium Hypochlorite
2.Well Construction Permit#: 0 1
list all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ijlntown 0
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) RResidential Water Supply(single) ❑ Sand Cement Grout ® Dry Clay
❑Industrial/Comrnercial ❑Residential Water Supply(shared) N Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7C For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundvvaterRemediation well mix- 1 yard
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage clean day-ZO yards
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
[)Geothermal(Closed Loop) ❑Tracer FILLED WITH CLEAN CLAY;
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
TAMPED IN 5 FT LIFTS; POURED PLUG; _
4.Date well(s)abandoned: 7/11/23 COVERED WITH CLEAN CLAY R E G�e t �D
5a.Well location: L II 9 t( ,(1,3
GAY KEEBLER 6
Facility/Owner Name Facility ID#(ifapplicable) S.Certification: l I. �;I�D }�r^;,�cp;P Un4
r�s^1408 STEVENS RD., WESTFIELD, NC 27053 1/ �BOGBOG�� 7/12'/2t
Physical Address,City,and Zip S' uture of Certified Well Contractor or Well Owner Date
STOKES 5080-73-96-87
By signing this forin, 1 hereby certify that the ivell(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constriction 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:
(ifivell Held,one latIong is sufficient) 9.Site diagram or additional well details:
36.499425 N -80.401314 �1r 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Airachu•ellcanstritetionnecord(s)ifai•ailable. F'ormtrltipleinjectionornon-watersupplywells
ONLY with the.rame ennstructiotrabandonivent,you can submit one forms. 10a. For All Wells; Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 52 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 36 (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: dry (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service,Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): A) loc.For Water Supply&Iniectiori 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): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016