WQ0006254_GW-30 Forms_20210518

WELL ABANDONMENT RECORD
I. Well Contractor Information:
Earl Wayne Thompson
W d I C ontraetorName torweII owner personally obaodaning well on hislher property
NCWC 2998-A
\C Well Corruactur C'crttliCstiun -Number
Ground Water Well And Pump Co
r ompaq tpoic
2. Well Construction Permit #:
Liv n11 pppllewhlr tnell c'onsineCtion pernrrrs R,e, UIC, Currr+$s slide. I'adaltra Vic.) iI blown
3. Wei use (check well use):
Water Supply Weil:
CJ Agricultural
OGeothetmal (IleatinglCooling Supply)
❑ in dust riallCOtnmerctaI
❑Munlclpal Public
❑Residential Water Supply (single)
❑ Res idon tial Water Supply (shared)
Cllrri =anon
Non -Water Supply Well:
A Man itari ne ❑Recav ery
❑Aquifar Rocharge
0Aquiler Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
QGcothcrmal (Heating/Cooling Return)
gCiroundwater Remediation
❑Sal iniry Harrier
ElStormwater Drainage
❑Subsidence Control
pTraccr
❑Other (explain under 7g)
4. Date wellis) abandoned: 4/29/2021
Sa, Well location:
Carolina Water Service, Inc of NC
Flit: i l i tyiOwner No mr
Corolla Village Rd, Corolla, NC
Physical Address. City-, and Lip
Currituck County NC
Coutny
W00006254
Facility Ili'+ (il'nppticable)
9937-30-7494
Parcel ldcnIilicatiorP No. IPIN I
5b. Latitude aitd longitude in degreesiminutsslseconds or declmuI degrees:
6I'weiI field, one iudlUng is sulti6cntI
N
W
For internal Lase ONVY
LYELL AMANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well constmetionldepth, only 1 GW-10 is needed. Indicate TOTAL NUMBER of
wells abandoned;
7b. Approximate volume of water rentaining in well(s): 5 gal (gal.)
FOR WATER SUPPLY WELLS ONLY:
7e. T. pe ofdisinreciant used: HTH
7d. Amount of disinfectant used: 1 14 CUP
7e. Sealing materials used (check all that apply):
Cl ''Meat Cement Grout a Bentonile Chips Or pellers
❑ Sand Cement Grout 0 Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout
• Bentunite Slurry
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
2 , 50 Pound bags
7g. Pro%ide a brief description of the ahandonrnenI procedure:
Sound Well ,free pore from surface, and hydrate,
Monitoring Well # j
A. Certification:
5131202 1
Signature arC'enified Well Contractor WOO Owner date
8•t' .t�igntng Ihis furor, I hereht+ ee7Y� that the welllr) axes ewers) ❑hrvrdorred in
accnrdenwe irith I5A MCA 02C.0100 ur 2C .02110 Well Coova) uclrint &andrtrd+'
and glint a cop.v idthix record has been provided tea the well uwucr.
9. Site diagram or additional well details:
Yotl may use the back of this page to provide additional well site details at, well
abandonment details. You may also Mach additional pages irnecessary_
CONSTR1;CTION DETAILS OF WELLISIBEING ABANDONED SUBMITTAL INSTRUCTIONS
ktat'h rrgll rr,rrsrrarrkrn rrer'POWvi iI availr+ble. Fur'muhode injuoton or uw+-uviersrrlrhly n'ells
ONL Y nvuh rhr sane rue+xtrur rinrvluhruvinuruclrr, me rare .sahrrrit onc,(ar+u.
6a. Well ID#:
61h. Total well depth: _3
6c. 13ombole diameter: 4 (irt.)
6d. Water level below ground surfaceV.
-
16a. For rill Wells: Submit this font within 30 days of completion of well
abandonment to the I'nllowingT
1)iv1sian of Water Resources, information Prates sing UnII,
1617 Mail Service Center, Raleigh, NC 27699-1617
IOb. For Iniection Wells: In addition to sending, the form to the addness in IOa
above, also submit one copy of this form within 30 days of completion a well
abandonnicot to the foliowing:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1630
6e. Outer casing length (if known); {ft.) IOc. For Water SuPyiy & Iniection Wes: In addition to sending; the form to the
addresses) above, also submit one copy of this foon within 30 days of cornpIction
iJ of well abandonment to the county health department of the county where
6f. Inner casingltubing length (if known) /' {ft.) abandoned,
6g. Screen Iength (if knuwn1: (ft.)
Fonn GW-30 North CBrnllPia Dopanmcmof Environmental Quality - 01Visiun or Water kcsuurccs Revised 2-22-2Q16

WELL ABANDONMENT RECORD
I. Well Contractor Information:
Ear! Wayne Thompson
W0I Coiitractor Name (nr well owner personal1)• nbandmingwcil on hisilier prapatyl
NCWC 2908-A
tic Well 0311tractor Certilication-No mbcr
Ground Water Well And Pump Co
Company �: +n�
i. Well Construction Permit #:
Liar u!! erpplfrnblr +001 ror+srrvL'rivn prr•mlrx (i.e_ UIC, Cnan±r. Siure, iariance, ere.) f knasm
3. Well use (check n ell use)i
Water Supple Well:
❑Agricultural
❑ Nf un icipal/Public
❑Geothermal (Heal inglCooling Sup13ty)
❑Residential Water Supply (single)
❑Irid us( CiailCommercia1
❑Residential Water Supply(shared)
Urngation
Von -Water Supply Weil:
111IMuniloring
QRecok ery
Injection Welk
❑Aquifer Rccharge
❑Groundwater Remediation
El Aqui 1er Slorage and Recovery
ElSalinity Barrier
C]Aquifcr Test
❑Stormwater Drainage
❑Experimental Technology
[]Subsidence Contml
❑Geothermal (Closed Loop)
[]Tracer
❑Gcothcnnal (Heatinc,,+ICoolin • Retnrn)
❑otiler (explain under 7g)
4. Date well(s) abandoned: 4/29/2021
So. Well location:
Carolina Water Service,Inc of NC W00006254
FaeiIityrOwner Name FaciIiry IDA (il'appiicablei
Corolla Village Rd, Corolla, NC
PlivsicaI Addn-5s. City, and Zip
Currituck County NC 9937-30-7494
Parcel Identitiraiiun No. (PIN
5b. Latitude and longitude in degreeslminuteslseeonds or decimal degrees:
frt'wcrl field, one !afliang is suitICictitl
IN W
Fur inierrsaI Use ONLi't
WELL. ABANDONMENT DETAILS
7a. For GeoprobelDPT or Clused-Loop Geothermal Wells having the stmte
welt cons u-uctionldepth, only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volatile of water remaining in we] l(s): 5 9 a l (gill.)
FOR WATER SUPPLY WELLS ONLY:
7c, Type of disinfectant used: HTH
7d. Amount a disinfectant used: 114 C U P
7e. Sealing materials used (check all that apply):
❑ Meat Cement Grout S Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ T]rlll Cuttings
❑ Specialty Grout
❑ Bentonite Slurry
❑ Gravel
G7 Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
2 , 50 Pound bags
7g, Pro %ide a brief description of the abandonment pro eedure:
Sound Well ,free pore from surface, and hydrate.
Monitoring Well # 7---
B. Certifica n:
5/3/2021
Signature of Certified Wrll C o n tractox WelI Ow nor Date
By signing thix fai'ar, I hereht, serf fc thnr tho nvll(t') woof (is -pre) uhandon d in
nevni-dwive with 15A NCAC D 2C 0100 or 2C .0206 li'ell Crrrictrtrctinil Strtndends
and !hell a copy of this r•ecorrl has been pr'uvidrd tv life well mvner•
9. Site diagram or additional well details:
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.
CONSTRUCTiOIN DETAILS OF WELL[5) BEING A13ANDONED SUBMITTAL INSTRUCTIONS
rlffa['Ir well e'nH.efRrrrinu r[tnrr11.�1 if arnilarrle l�nr m+ilriplr iujrciiva wraur-tra![•r sryrplr uvlls
I].YL 3' will+ rl+c nrrrur erritxtr�rc'Irnuhilrurtdnirererrr, }rrrr cwri .eirl�rrut eerie (nos. _ _
6a. Well TD#:
fib. Total well depth:
o `+ Ll
6c. Borehole diameter: 4 (in.)
6d. Water level below ground surface: P (ft.)
MIA. Fnr :11i Wells: Submit this forrn within 3t1 days it completton of well
abandonment to the following:
Dirision of "'ater Resources, information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Init! etion Wells: in addition to sending the form to the address in I0a
above, also stibruit one copy Of this foltm within 30 days of completion of Weil
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center. Raleigh, NC 27699-1636
6e. Onter• casing length (if Imuivn): (ft.) IUc. For Water Supply & Injection Wells: in addition to sending the [form to the
addresses) abate, also submit one copy ol'tliis form within 30 days ol'completion
Ir of well abandumncnt to the county health department of dtc county where
bf. Inner eusingllubing length (if known): D,) abandoned.
6g, Screen length (if knoivn): (ft.)
Fo+m GIl -30 North Cam Iina Mparlmcnt ofEnvirontnenlal Qua Iity - Division of WaterRcsources Roviwd 2-22 2016

WELL ABANDONMENT RECORD
1. Well Contractor information:
Earl Wayne Thompson
Well Contractor Name (or well owner personally abandoning well on his/her property)
NCWC 2908-A
NC Well Contractor Certification Number
Ground Water Well And Pump Co
Company Nano
2. Well Construction Permit #: _
List all applicable well consina-lion permits (ve. UIC. Cowin% State, Paricowe, etc.) ijknotrn
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Municipal/Public
❑Geothermal (Heating/Cooling Supply)
❑Residential Water Supply (single)
❑industrial/Commercial
❑Residential Water Supply (shared)
❑irri *ation
Non -Water Supply Well:
IRJ Moni toring
❑ Recovery
injection Well:
❑Aquifer Recharge
❑Groundwater Remediation
❑Aquifer Storage and Recovery
❑Salinity Barrier
❑Aquifer Test
❑Stormwater Drainage
❑Experimental Technology
❑Subsidence Control
❑Geothermal (Closed Loop) ❑Tracer
❑Geothermal (Heating/Cooling Rettun) ❑Other (explain under
4. Date well(s) abandoned: 4/29/2021
5a. Well location:
Facility/Owner Name
Physical Address, City, and Zip
Currituck County NC
County
Facility iD# (it'applicable)
Parcel identification No. (PiN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wc11 ticld, one lat/long is sufficient)
N
For internal Use ONLY;
W"ELL .ABANDONME.N'T DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:_ __ �-
7b. Approximate volume of water remaining in well(s): 5 gal (gal )
FOR WATER SUPPLY WELLS ON
LILY:
7c. Type of disinfectant used: HTH
7d. Amount of disinfectant used: 1 /4 CUP
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
9 Bentonite Chips or Pellets
❑ Sand Cement Grout
❑ Dry Clay
❑ Concrete Grout
❑ Drill Cuttings
❑ Specialty Grout
❑ Gravel
❑ Bentonite Slurry
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
2 , 50 Pound bags
7g. Provide a brief description of the abandonment procedure:
Sound Well ,free pore from surface, and hydrate.
Monitoring Well # 3
S. Crrtif3ca st:
5/3/2021
Signature ofCartitied Wdl Cuntract pr Wall Owner Date
By signing this Jbrnt, 1 here%tt certify that the well(s) eras (were) abandoned in
accordance with 15A NCAC 02C.0100 or 2C.0200 bVe(( Construction Standards
and that a copy of this record has been provided to the ive(( owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
W
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach n�ell consouction records) ifavailable. Formtltiple byection or ran- water suppM wells
OiNL P with the .scone construction/abmtdantnent, rot(curt submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a. Well iD#: abandonment to the following:
L Division of Water Resources, information Processing Unit,
6b. Total well depth: ` _(ft.) 1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For injection Wells: ht addition to sending the form to the address in 10a
6c. Borehole diameter: 4 (in,) above, also submit one copy of this fonn within 30 days of completion of well
abandonment to the following:
6d. Water level below ground surface: e
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
6e. Outer casing length (if known): (ft.) 10c. For Water Supply & inlection 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
6f. inner casing/tubing length (if known): i ft. abandoned.
6g. Screen length (if known): (ft.)
Form OW-30 North Carolina Departnient of Environniental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Infnrmation:
Earl Wayne Thompson
1ve11 Contractor Name for well owner personaIIy shandoning well on hi viler property)
NCWC 2908-A
C W 11 C011l rarWr C•,• rt ill �:r 00 n NUMN!r
Ground Water Well And Pump Co
Company Narnc
2. Well Construction Permit il:
lrsr all applicable tsvilcnkarrrrclin+r permits t+.r. CIIC'. Cannh•, Stair. Variance erc.l lf-kr+nrr,r
3. Well use (check well use):
Water Supply Well:
ClAgricultural ❑MunieipaUPublic
❑GcnthentfaI (HeatinglCooling Supply) ❑Residential Water Supply (single)
❑ Ind ustriaVCommercial QResiden iia] WatcrSup ply (shared)
Non -Water Supply Well:
R Man iteri ne ❑ Recovery
❑Aquifer Recharge
❑Groundwater Rem edialion
❑Aquifer Siorage and Rceoveiy
❑Salinity Barrier
L7Aquifer Test
0Stomiwaler Drainage
❑rxperitnental Technology
ClSuhsidence Control
015cothennal(Closed Loop)
pMater
❑Geothermal (Heating/Cooling Retum)
DOdier (explain under 7g)
4. Date well(s) abandoned: 4r 29'20L 1
Sa. Well location:
Carolina Water Service, Inc of NC WQ0006254
FacilitylOwner Name Facility IDO I i I' appi ieable)
Coroalla Village Rd, Corolla,NC
Physical .Addn•ss. City. and Zip 9937-30-7494
Currituck County NC
Counly
PaNd ldenufiCauon No. IPIN I
5b. Latitude and longitude In degreeslminuteslseconds or decimal degrees:
Irl wctl licid' one tat']ong is suflieictn)
N
W
For InternnI Use ONLY:
WELL ABANDONMENT DETAILS
79. For GeoprohelDPT or Closed -Loup Geothermal Wells having the same
well construetionidepth, only 1 GW-30 is needed, Indicate TOTAL NUMBER of
wells abandoned:
7b. Appro�1mat e volume of water remaining in welI(s): 5 gal (gal.)
FOR WATER SUPPLY NVULLS ONLY:
7c. Type of disinfectant used: HTH
7d. Amount of disinfectant used: 1 /4 CU P
7e. Sealing materials used (check all that apply):
C1 '.Neat Cement Grout
© Bentonite Chips or Pellets
IJ Sand Cement Grout
0 Dry Clay
13 Concrete Grout
C] Drill Cuttings
❑ Specialty Grout
❑ Gravel
❑ Bentonite Slurry
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
2 , 50 Pound bags
7g. Provide a brief description of the ahand(in menI procedure:
Sound Well ,free pore from surface, and hydrate.
Monitoring Well #`
8. Certification:
&q�k (.0 5/3/2021
Sigwture arCeniNed Wei Contra rtor or Well Owner Date
By sighing this fnrin, l homhv cerufv Aral the "vflls) wa.v fnvele.r aha idmied ill
oe•cwWwoce wilh ISfl NCAC 02C , 0100 ar 2C MOO heel! Consimclitm Standards
and rhul a rhpr df this record hus been provided In the rtwil eeu•uer.
9, Site diagram or additional welt details:
You may use the back or this page to provide additional well site details or well
abandonment dclaits. You may also attach additional pages if neressary.
CONSTRUCTION DETAILS OF WE i (S) BEING ABANDONED SUBMITTAL INSTRLCTIONS
dllucharllrtinrah'r+r+lnrrltrurvlrr)ijavailahle•. F+.rare+7+iplri+jdrrin+lnrtrn0+-nxxer"eFJ75.14xlls
❑]Vl-Y korl. rho .warm rmrrny+ralnnlnhnndnumnur- 1-1 ran ud mil mm rnrm
[4 71Ifi17'A
66. Total well depth: fft.)
6c. Borehole diameter:
6d. Water level belove ground surface: 9 ft.)
10a. For All Wells: Submit this font within 30 days of completion of well
abandonment to the following --
Division or Water Resources, Information Processing unit,
1617 Nail Serr•ice Center, Raleigh, NC 27699-1617
10b. For Injection Wells: ]n addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of eornpietion of well
abandonment to the following:
Division of Water Resources, Underground injection Control Program,
1636 i17ail Service Center. Raleigh, NC 27699-1636
6e. Outer casing length (if known): 00 tile. For Water Suppiv & In ecti n Wells: In addition to sending the Corm to the
address(es) above, also submit one copy of this form wiIli in 30 days of cotnplelion
of well abandonment to the county health department of the county where
6r. Inner casingltubing length (if known): ��{it.j abandoned.
6g. Screen length Rif known): (ft.)
Forrn G11'-30 North Carolina Depanmcnt urEnviroamcnlal paality • Divisioil of WacetResaurces Xevised a-2Z-Vi16
[I