Stokes_Well Abandonment_20231229

WELL, ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAIL'S
J. Michael Venable 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
NCWC-2079-A wells abandoned:
r
NC well Contractor Certification Number Approximate volume of water remaining in well(s): 0
7b.App (gat.)
Venable Brothers Well Const., Inc. FOR WATER SUPPLY WELLS i ONLY:
Company Name C',alcium H ochlorite
3902 7c.Type of disinfectant used: yp
2.Well Construction Permit tl: j
List all applicable mell construction permits(he.UIC,County,State,1'artance,etc.)tjknmrn
7d.Amount of disinfectant used:, N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check albthat apply):
❑Agricultural OMunicipal/Public ❑Neat Cement Grout I ❑Bentonite Chips or Pellets
❑Geothennal(Heating/Cooling Supply) IlResidential Water Supply(single) ❑ Sand Cement Grout IN Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑lure ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ' ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRe'mediation CLEAN CLAY-45 YDS
❑Aquifer Storage and Recovery ❑Salinity Barrier 1
QAquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control a
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer FILLED BOTTOM TO'TOP WITR'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) �' ,�"e; � �! A
CLAY, TAMPED 1N 5 FT LIFTS.
4.Date well(s)abandoned: 8/14/23 l-
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5a.Well location: I Intofffinzil P •-- f
ELOISE MABE DWOMOG
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
4218 HWY 8 SOUTH, WALNUT COVE, NC 27052 � 8/17/23
Si
Physical Address,City,and Zip ure of Certified Well Contractor or Well Owner Date
STOKES 6944-06-43-74
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: l ;
(ifsve11,60d,=0lutll°ngis suiFicrcnt) 9.Site diagram or additional well deiails:
36.34409 N -80.22051 You may use the back`of this pagelto provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(Sl BEING ABANDONED .--SUBMITTAL INSTRUCTIONS
llaclrx'ellconstrnctianreeord(s)ifmlailable.For"whiple htfection or non-water supply wells
ONLY with the same constrnctionlabandonment you can submit one forme, 10a. For All Wells Submit this form within 30 days of completion of well
69.Well ID4: abandonment to the following:
i
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 72 (ft) 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 60 above,also submit one copy of this form within 30 days of completion of well
(in.) abandonment to the following:
I
6d.Water level below ground surface: DRY (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service C nier,Raleigh,NC 27699-1636
6e.Outer casing length(if known): A) 10c.For Water Sunnly&Iniectioit 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): (ft.) abandoned.
6g.Screen length(if known): (it)
Form GW-30 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22.2016