Stokes_Well Abandonment_20241025

WELL ABANDONMENT RECORD `, For lnw iIt7wONIY
This form can be used for single or intdtiple Hells
1.Well Contractor Information ' W'FLL ABANDONMFNT DETAI[S
Josh Holt 7a.Number of wells[icing abanduned: 1
Wc11 0,1d ictoo Nance for hell ohrter permiWit almiWiting Neil on lit tar prttpcm t F-�tr "Idop& orletliruf ,r .rat-inner tirpph wells ON.I wA the axnt
.,.,t.rrrr<nwi,d,,url+trAirnr.i.ar tsar r>,hxN,air Firm
4698A
NC Wrll Nnn#tcr
7b.Appntximate ud e of er'In wat remaining in%%ell(sl: Igal.l
Conrmaar Ccrl f ficalion
SAEDACCO MR WATIER SUPPLY WFLI S MIA:
Contpam Name 7e.Type of disinfectant used:
2.W eli Censtttiction Pet'tuit C, ,
Ltaf .i r f uvftn'•Aw.14"drer 1"fiote etc.)tt1knim" 74,Anamo of dMnlectarnt Yse/I:
3.Well use(check:well u w)-
Water Supph Well: 7C Sealing materials aced(check all that apple):
❑Agmultural ❑Ntunicipal:Ptibla ® Neat Cement Groat r I I Hcotonite Chips or Pellets
❑(ieothcrrtal(Heart 110'notiRig 44Vl}I ❑ResidrnttA Water Supph (singic) ❑ Sand(lenient Cuonr-• ,:'I— '•r [3 Un CUN
❑Industrial,Comnicrcial ❑Rtsrdrtatal Water Supph•(shared) ❑Concrete Grout O r T 2 �� 2024 0 Drill C inking
❑Im 'twn ❑ ct Spealt} Grout ❑Gmtl
Nrtn-Water Nuppl%Well: ❑ Betltoritle Shim f. 0,0dier(eNp1:tttt Iider 7g)
10,1011uonuL ❑Reco%en
njectinn%'ell: 7f,For each material sleeked i n idv anuttunl'If MAICrial+used:
13Aquita Recharge ❑(iroundt%ater Rentc(ltatiou Neat Cem.:141lb ,Wtr:17gal. Sand Cem. :ib ,wtr:gal.
❑Aquder Storage and Remen ❑Saline Harnett
❑Ayurfet Test ❑Slorim%ater Drltmge
❑Expenntental Iechnotogi ❑Srtbsidence C'oldtol 71t,Pr®%ide a brief description of the aliandrinment pnwedun:
❑GeoiheroaW(Closed Loop) 11Tracer
tremie grouted
❑Geothertnl(Head 'Coolie•R c turn) I.IOther ic\ 7 atn under . )
k.Date wclltsl abandoned: 10/15/24
ia.«'cll Mwalion:
King Ethel Oil Company
t,witro(ht).;tNim.. f.a,tlm IDstitapplrtbk, li•Cenifkt'alilNi;
C//d
125 Itkeadowbrook Dr. King, NC 27021 10/15/2024
Ph%sical Add.Cie,and Zip Sr i +>` dll Corrraae a or Well owner Da;:
Stokes lk.rigntig thwfiv ot, 1 ketieby cerhfr that the wellfs! wux(weref ahillfkkned in
Cotmtx I'.n. I h1nUIK:;iu i Nt, XI\i txYrrtkffitc with IJA,ICAC 02C.0100 or 2C O:OO ff'ril Constntction•S'kinrlim/.x
trod that a copy of this record has been promiloid to the weN owner.
Sh.Latitude and liingitulle in dct;rrrstminutrst%etsind%or dmimal dt•(;n11"C
pl hc11 ftid.otic Lit litn_n Mli.aati; 9.Site diagram or additional well dCfail9:
You ma% me the back,of this page to prof de addihonah%tell site detads or sell
abandovintert de(ads. `tou ttla% also altach aldilmnall POOLS If Wessan
CONSTRIA-TION DETAILS OF WE.LIASI BI 1,(1 XB(\D0N1*D SUBNIITTAL INSTRUCTIO'VS
.Ifrtuh wr17 n•+urd• {t atwheb!a•. ..,. •. a.tk7 sup�h
welkf ONLY with the swot•twafrrftfwn a bcoulr,twitvtt_1i.,n cue sxhnril nvn H rm. Isla. For All Weds: Submit thts form nubm 30 da)s of completion of%%nil
abatrttoumcnr to the follnwing
ba.Well ID+t:MW-2
Division of W'ner Rewiurces,Information Pructvang 11 nit,
MR.Total we•11(kpth: 15
1617 Mail Scrxice('enter,Raleigh,N('2 7 699-161 7
(h.)
Into. For Irkir en Wdis: In addition to sending the form to the address in 10•a
abmc- also submd otw eery% of this form%%itlpn III days of completion of%%ell
Iw.Rtinhtdc diameter;2 kin.) abandonment to the lollo%%utt:
pi%Wown of Water Resources,I.n(k•M-o-fo rnd Injection Conirtd Program.
(A W Hier k%tI blow around wrfaec: 6 (h.) 1636 Mail Scnkec Ccnter,Raleigh,N('27699-16336
Ittc.For Water Suntih & Ini Ntllin Wells: kn addition to sending the forts to
hc.Outer casinp len;gh it(knot%tit: (tt•1 the addresses) Axne. also subniil one cop} of this fOmt %%iihtn to days of
completion of%%ell abandonment to the couMl health dcparmicnit of the calm
a here ah aruinned
of.Inner c asinr�tubin�lent,Kh tit'kiinh it): (h.l
screen Icn::ili iif knor%n1:10 1 (R.1
" t t%- I I Noah Carulim DeWi err of En%uonni:w and Natural Resomi:s Dn iswn of 1w'ater R aouri s Rix r5td AugL9 1r)1 i