Stokes_Well Abandonment_20240624

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CHANDLER THOMAS 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) Far multiple injection or non-water supply wells ONLY with the some
construction'abandonment,you can submit one form.
B -4621 1.0
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 wel/construction permits(i.e.County,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 ❑Municipal/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: El Bentonite Slurry ❑Other(explain under 7g)
WIMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.0 GALLONS
❑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 ABANDONED VIA TRMIEIFE#J1>'ITMIPT-ONITE SLURRY
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g) .cr ram, t
4.Date well(s)abandoned: 05/20/24
5a.Well location If�Gr,� •'� 7'ry�"y t.1ti,
BELEWS CREEK STEAM STATION
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
3195 PINE HALL ROAD BELEWS CREEK 27009 �` 06/15/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
STOKES 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 fat/long is sufficient) 9.Site diagram or additional well details:
36° 17 20.54 800 04' 24.22" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLIS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ON1.Y 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#: AB-5S abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
18.0 1617 Mail Service Center,Raleigh,NC 27699-1617
(ft.)
10b. For Infection Wells: In addition to sending the form to the address in l0a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2'0 (in•) abandonment to the following:
6d.Water level below round surface: 1 1.0 (ft Division of Water Quality,Underground Injection Control Program,
g ) 1636 Mail Service Center,Raleigh,NC 27699-1636
1Oc. For Water Suooly&Infection 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
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013