Currituck_Well Abandonment_20230127

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
7 "Ay J ( t W I1 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
wells abandoned: 1
LIIFil8
NC Well Contractor Certification Number _o /'T- 7b.Approximate volume of water remaining in well(s): (gal.)
•
C4r0✓4- �'ef vt i 4nd Cons- ualI Dli L� FOR WATER SUPPLY WELLS ONLY:
Company Name t 7c.Type of disinfectant used:
2.Well Construction Permit#: 3111�30 W W 1/3 `tr
List all applicable well construction permits(i.e.U/C.County.State.Variance.etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
f
Water Supply Well: 7e.Sealing materials used(check all(that apply.
❑Agricultural 0/Municipal/Public 0 Neat Cement Grout I ientonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) !(Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation - ❑•Specialty Grout- • 0 Gravel,
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation k b„r
0 Aquifer Storage and Recovery 0 Salinity Barrier �l
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of;the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ��• 1 �t ��/�
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) G-tk p I Pe .P1,u,5� 1 -Ate 4 t�1pLd Q""•-'
t� 7 Fi lek (pou'ectt) 3/�s be�-�-b via (et u d-t 1
4.Date well(s)abandoned: /(�9 i )Z(/ n+ -:_'
• ��I l .fr 0�E Li
5a.Well location:
�" Owe. SoiciPc ler L-c- JQNI 92023
Facility/Owner Name Facility IDS(if applicable) 8.Certification: I InformatiDn Pri.k°r� Lin.
24�5 5awd -odd lee Rd l lira l Z 11 i � / c :c�;; 0 ' ZR az--
Physical Address.ICi y.and Zip Signature a Ce ed Well ontract or Well Owner Date
(,krrl By signing this form.I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with/5A 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 lat/loonng is sufficient) t t' 9.Site diagram or additional well details:
34° L-1 f SRO' N i S r o 51 2q W 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 WELL(S)BEING ABANDONED -- - --SUBMITTAL INSTRUCTIONS'
Attach well construction record(s)if available.For multiple injection or non-water supply wells
ONLY with the same rnnstructinn/abandnnment,you ran submit one form. 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: I 1 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
1.
"'uV 'w 10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above,also submit one copy of this form within 30 days of completion of well
�� abandonment to the following: Y
f
6d.Water level below ground surface: (ft.) Division of Water Resources,f Underground Injection Control Program,
1636 Mail Service Ce ter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft) 10c.For Water Supply&Iniectil mWells: 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 casin g/ lengthabandoned.
tub'tog (if(mown): (ft)
6g.Screen length(if known): (ft.)
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
•
17�py� Y J {ram/�i5lA 7a.For Geoprobe/DPT or Closed-hoop Geothermal Wells having the same
.\-. Well Contractor Name(or well owner personallyb abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
thil wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): U.h.1 Wi. (gal.)
I
CM b Uit Seroia 44 Covifintbkoil LLL' FOR WATER SUPPLY WELLS ONLY:
Company Name
2 7��O �A, 2�, 7c.Type of disinfectant used:
2.Well Construction Permit#: 3 3 W f&13
List all applicable well construction permits(i.e.U/C.County.State.Variance.etc.)if known
7d.Amount of disinfectant used: ,
i.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that app ):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 1 I ZBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) V2esidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout 0 Drill Cuttings
___ _ - ❑Irrigation - - ❑_Specialiy Grout -- 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation t/Z b
❑Aquifer Storage and Recovery ❑Salinity Barrier 4
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 1
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer l/ ry' l
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Cu{- Phi f if() R1ksk W( Gf nAxi'rG( G.114
'/ poulrPP ?If bet/Lloi1(e bc. - t: i,E'T"1
4.Date well(s)abandoned: �I ZLI ZZZ.-
q�`:,y ; i1 _ -�
��► h"I cult
L : 2023
5a.Well location: J AN 2
Jilesk Pa. 1
S.Certification: ; t ''C.l'3r^C5v'-. ng(,i-r:l
Facility/Owner Name Facility ID#(if applicable) 1(»tr+
ILO Oce4A Pecs I/ Co(0U .1 L1 qt Z1 9/01/zoZ7_
. Physical Address.City,and Zip Signature Certifi 'ell Con ctor or Well Owner Date
CU,rrl t'Wil 010 Zi coo Aga 6DCOU By signing this form.I hereby cerlifv that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has hen provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 11 / 9.Site diagram or additional well details:
t�0 Z r�,S I N/ • �b Z� W 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 WELL(S)BEING ABANDONED - SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable.For multiple injection or non-water.supply wells
ONLY 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#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: b (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: 6 (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: 2 f
(ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
pp
6e.Outer casing length(if known): k& (ft i
) 10c.For Water Supply&Injection 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): (ft) abandoned.
"'— 7 6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
. I

•
•
WELL ABANDONMENT RECORD • For Internal Use ONLY: .. •
I ..
1.Well Contractor Information: . WELL ABANDONMENT DETAILS •
•
Corey D. Futral "' .. .. 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
4300-B wells abandoned: I i
•NC Well Contractor Certification Number . ' 7b.Approximate volume of water'remaining in well(s): (gal.)
• CATLIN Engineers and Scientists •
FOR WATER SUPPLY WELLS ONLY: .
Company Name .
7c.Type of disinfectant used: .
2.Well Construction Permit#: NA '
List all applicable well construction permits(i.e.WC,County,State,Variance,etc)if known •
7d.Amount.of disinfectant used: .. '
• 3.Well use(check well use): .
Water Supply Well: 7e.'Sealing materials used(cheek all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout •Bentonite Chips or Pellets
• ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout. I -. ❑ Dry•Clay
. ❑Industrial/Commercial ❑Residential Water Supply(shared). 0 Concrete Grout 0 Drill Cuttings
❑Irrigation . . O Specialty Grout ❑Gravel
Non-Water Supply Well: 0 Bentonite:Slurry, • . •Other(explain under 7g)
•Monitoring, ;. " :ORecovery• '
Injection Well: • 7f:For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets . — 12.5 lbs
. ❑Aquifer Storage and Recovery • • '•oSalinity Barrier . . •
❑Aquifer Test '❑Stormwater Drainage Topsoil .. ' . . "' 15 lbs
•
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) . ❑Tracer
❑Geothermal(Heating/Cooling Return) , ❑Other(explain under 7g)•• Stick-up and 5 feet of PVC removed. Hydrated
bentonite to seal the area and topsoil to the -
. 01/19/2023 • _
4,Date well(s)abandoned: Surface. '=� �° ') ja t�` •
• 5a.Well location: .
NCDEQ - Grandy Union'76 - NA ' . , • BAN 2 7 Z023
•
• Facility/Owner Name Facility ID#(if applicable) . 8:Certification:
J ►�, Inf cmB.i n PrreTr:•:�i:�g I'rli
6334 Caratoke Highway, Grandy, NC -- ••• -. - . . U . . . " 1/27i2029 _
•
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date - -
Currituck 9912-72-6985
By signing this form, I hereby certify that the well(s).ivas'(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: -
(ifwell field,one lat/long is sufficient) • 9.Site diagram or additional welI'details: •
36.2466 - N -77.8873 • •
W You may use the back of this page•to provide additiotial•well site details or well •
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS • •
Attach well construction record(s)ifavailable.For multiple injection or not-seater supply wells
ONLY with the same construction(abandonmerit,sou can submit one form. '' -
• 10a. For All Wells: Submit.this form within 30 days of completion of well
6a.Well ID# MW-2 • "- • abandonment to the following:
Division•of Water Resources,Information Processing Unit,
13 1617 Mail Service Center,Raleigh,NC 27699-1617 ' -
6b.Total well depth: • •(ft.) ... -
• • - lOb.For Injection Wells: In addition to sending the form-to the address in 10a
•• • 8.25. • above, also submit one copy of this form within 30 days of completion of well
• 6c.Borehole diameter: (in:) •
- abandonment'to the following: -
4.03
6d. •
Water level below ground surface: (ft.) . .Division of Water Resources,Underground"Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1
i
6e.Outer casing length(if known):'NA (ft) 10c.For Rater Supply&Injection 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/tubipg letigth(if known): 3 (ft.) abandoned.
y .
• 6g.Screen length(if known): 10 ' (ft.) ' '
- Form GW-30 .. •. . North Carolina Department of Environmental Quality-Division of Water Resources • Revised 2-22-2016 .
i

. . WELL ABANDONMENT RECORD For Internal Use ONLY:
i
. 1.Well Contractor Information_: • WELL ABANDONMENT DETAILS
CoreyD..Futral .. r
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
4300-B . _ wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
• CATLIN EnglneerS and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name . -
• 7c.Type of disinfectant used:
2.Well Construction Permit#: NA
List all applicable well construction permits.(i.e.tlIC,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
❑Irrigation ' .. . .. ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry IaJ_ Other(explain under 7g) •
•Monitoring ❑Recovery
Injection Well: • - 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge • ❑Groundwater Remediation Bentonite Pellets' ., • '- 17•Ibs
❑Aquifer Storage and Recovery . ❑Salinity Barrier . '
• ❑Aquifer Test ' ' ❑Stormwater Drainage Concrete 12.5 Ibs •
❑Experimental Technology ❑Subsidence Control
7g..Provide a brief description of the abandonment procedure: •
❑Geothermal(Closed Loop) ❑Tracer • Well abandoned in place with hydrated bentonite-
❑Geotheimal(Heating/Cooling Return) ' DOther(explain under 7g) '
pellets to within 6 inches of,surfa6e...and•-topped ry. s e
• 4.Date well(s)abandoned: 01/19/2023 with,concrete to existing grade. 2`':""'""'1�_d. ; II -.
5a.Wellloeation: JAIN 2023
'
NCDEQ= Grandy Union 76 NA •,mmap l , r „:ye ha link
• Facility/Owner Name Facility ID#(if applicable) , S.Certification: • • . ra.r
b.re Qr LS0Lz
6334 Caratoke Highway, Grandy, NC .. ' ". - 1/27/2023
•
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner • Date
Currituck " 9912-72-6985 •
•By signing this form, I hereby certify that the ivell(s)•ivas (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1.5A 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 lat/long is sufficient) ' ' . . 9.Site diagram or additional well:details: -
36.2466 N -77.8873 `l ' ' 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 •
Attach well construction record(s)ifavailable.For inultiple injection or non-water supply wells
ONLY with'the same construction/abandonment,you don submit one form. '
. , 10a. For All Wells: Submit_this form within 30 days of completion of well
6a.Well ID# MW-4 .' • abandonment to the following: • •• •
• Division of Water Resources,Information Processing Unit,. .
15 1617 Mail Service Center,Raleigh,NC 27699-1617 ••
6b.Total well depth: (ft.) •
- . 10b.For Infection Wells: In'addition to sending the form'to the address in 10a .-
. 6c.Borehole.diameter: 8.25 (in.) . ' • above, also submit one copy of•this form within 30 days of completion of well
abandonment to the following: .
5.09 • Division of Water Resources,Underground Injection Control Program, •
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
•NA 10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)'
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): •5 - (ft.) abandoned.
• 6g.Screen length(if known): 10• •• • - (ft.) • . --
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
l ; .

WELL ABANDONMENT RECORD For Internal Use ONLY: '
ii .
. 1.Well Contractor Information: WELL ABANDONMENT DETAILS •
Corey D. Futral 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
•
4300-B wells abandoned: •
NC Well Contractor Certification Number • 7b.Approximate volume of water remaining in well(s): _. • (gal)
tt
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
• 7c.Type of disinfectant used: _
• 2.Well Construction Permit#: NA •.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known •.- n •
i
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 _• 0 Neat Cement Gtout II-Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout, ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑.Concrete Grout 0 Drill Cuttings ' •
.❑Irrigation . . . . • O Specialty Grout 0 Gravel ..
Non-Water Supply Well: 0 Bentonite Slurry_ U Other(explain under 7g)
. •Monitoting .: ❑Recovery
Injection Well: 7f.For each material selected.above,provide amount.of materials used:
❑Aquifer Recharge ' ❑GroundwaterRemediation Bentonite Pellets • , "' 12.lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier .
❑Aquifer Test ❑Stormwater Drainage Concrete 4 . - 12.5 lbs
❑Experimental Technology ❑Subsidence Control .
7g.Provide a brief description'of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Well abandoned in place with hydrated Bentonite
pellets to within 6 inches of surface and topped
• 01/19/2023 -{ n- ;r",p •
4.Date wells abandoned: ' (-� c,, <
() with concrete to existing grade. ; ,�;��;;�,�,,�.�,5 �,� a,...�.~'
5a.Well location: JANI ,n��
NCDEQ- Grandy Union 76 ,NA -
Facility/Owner Name Facility.1D#(if applicable) 8.Certification: � cb, G� --%' sorira:;'sr.i1p./T.,S*,3••:rg l,rn:
•
• 6334 Caratoke Highway, Grandy, NC . C `J -j 9„y 7Y32 3
Physical Address,City,and Zip • Signature of Certified Well Contractor orWell Owner Date
- Currituck 9912-72-6985 . .
By signing this form, I hereby certU'that the well(s) Was(were) abandoned in
County Parcel Identification No.(PIN) • dccorddnce 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 lat/long is sufficient) 9.Site diagram or additional well'details:
36.2466 N• -77.8873 • �, 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same'construction/abandonment,volt can submit one fynn.
10a:For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-5 abandonment to the following:"
•
- n .
Division of Water Resources,Information Processing Unit,
9 '1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
•-10b:For Iniection Wells:•In addition to sending the form"to the address in 10a
6c.Borehole diameter: 8.25 (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: 5.42 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 21699-1636
d'
NA 10c.For Water.Sunaly&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): _ (ft.)
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): Unknown (ft) abandoned.
i
6g.Screen length(if known): Unknown (ft.)
•
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1
1.Well Contractor Information: WELL ABANDONMENT DETAILS' •
i 1 .
Corey D. Futral 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well ContractorName(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
430O-B wells abandoned:
. .
• NC Well Contractor Certification Number 7b.Approximate volume of water fri emaining in well(s): (gal.)
CATLIN-Engineers and Scientists FOR WATER SUPPLY WELLS ONLY: '
•
Company Name .
7c.Type of disinfectant used:
2.Well Construction Permit#: NA ••. : .
List all applicable well construction permits(i.e.UIC,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 e'Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 0 Dry.Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout •
0 Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: • 0 Bentonite Sluny •Other(explain under 7g) •
• •Monitoring ORecovery - •
• Injection Well: 7f.For each material selected above,provide amount of materials used: ••
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pelletsi, . — 12•Ibs .
❑Aquifer Storage and Recovery ❑Salinity Barrier .
❑Aquifer Test • ❑StormwaterDrainage Topsoil . • "' 15 lbs . . .
❑Experimental Technology' ❑Subsidence Control ' •
7g.Provide a brief description'of the abandonment procedure:
❑Geothermal(Closed Loop). ❑Tracer Well abandoned in plebe with hydrated bentonite
❑Geothermal(Heating/Cooling Return) • ❑Other(explain under 7g)
pellets. Three feet of PVC, well.shield, and concrete
01/19/2023
4.Date well(s)abandoned: E",k, ! .1.:..::.; {iiz F h
removed. Soil to grade. I ; '''a; ,i«
5a.Well location: JAN 2
NCDEQ- Grandy Union 76 ' NA ?�?3
Facility/Owner Name Faci!ity-lDff(if applicable) 8.Certification: eb' •--" ril^,.,`,i n Pri-.‘r 3•^,r!ng I..Ini
' • 6334 Caratoke Highway, Grandy,.NC . . . 1° ` 23
•
Physical Address,City,and Zip Signature of Certified Well Contractor or.Well Owner Date
Currituck . 9912-72-6985
By signing this form, 1 hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with/SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one lat/long is sufficient) 9.Site diagram or additional wellidetails:
36.2466 N -77.8873 . �, 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 WELL(S)BEING ABANDONED• ' SUBMITTAL INSTRUCTIONS '
Attach,well construction record(s)ifavailable.For multiple injection ornon<tivatersupply wells -
• ONLY with the same construction/ahandonment,yoti can submit one form. •
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# M W-6 ' abandonment to the following:•
•
Division-of Water Resources,Information Processing Unit,
9 1617 Mail Service Center•,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
• 10b.For Infection Wells: -In:addition to sending the form to the_address in 10a
• 8.25 above, also submit one copy of this form within 30 days of completion of well '
6c.Borehole diameter: _ _ _ ,_(in.)
abandonment to the following:
-6d.Water level below ground surface: 5.69 • : (ft.) Division of Water Resources,Underground Injection Control Program, .
. 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length.(if known): NA ' . (ft.) 10c.For Water Suaaly&Infection 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): Unknown (ft) abandoned. '
II
• 6g.Screen length(if known): Unknown. (ft.)
. • j I . .
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
•
1
{
r i

WELL Al ANDONNIE`NT RECORD _, • For Internal Use ONLY: i J
I .
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CoreyD. Futral
7a.For Geeprobe/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 GW30- ,is needed. Indicate TOTAL NUMBER of
' 4300-B " wells abandoned:
NC Well Contractor Certification Number • 7b.Approximate volume of water remaining in well(s): - (gal.)
CATLIN Engineers and'Scientists FOR WATER SUPPLY WELLS ONLY: '
Company Name .
•
7c.Type of disinfectant used:
2.Well Construction Permit#: NA
List all applicable well construction permits(i.e.UIC,County,Slate,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 0 Neat Cement Grout • Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑ Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared). ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation 0 Specialty Grout ❑ Gravel ,
Non-Water Supply Well: ' ❑ Bentonite Slurry, •Other(explain under 7g)
•Monitoring ''❑Recovery ,
Injection Well: • 7f.For each material selected above,provide amount of materials used:
• ❑Aquifer Recharge ❑GroundwaterRemediation • Bentonite Pellets . ' ^' 12 lbs .
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑StormwaterDrainage Topsoil 15lbs
El Experimental Technology ❑Subsidence Control
7g'.Provide a brief description of the abandonment procedure: •.
' ,- -❑Geothermal(Closed Loop) ❑Tracer .
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g) •
Stick-up and.5 feet of PVC removed. Hydrated .
bentonite to seal the area and topsoil to grade.
. '01/19/2023 • CC_• ...,f.. -.,, f-- '.. 4.Date well(s)abandoned: _ - _ , t,.'� It
5a.Well location: •
NCDEQ- Grandy Union 76 NA . . .. • . �A� 2 2�23
Facility/Owner Name Facility-IDll(if applicable) - 8:Certification: ' fvi l"atiDn Prr.T.:ilf- ng Una'
6334 Caratoke Highway, Grandy, NC ' , .. -. . `J 'C� ' 1')fiiidY3
Physical Address,City,and Zip • • . ' Signature of Certified Well Contractor or Well Owner Date
•Currituck -9912-72-6985 . - -- ' ' - • :
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 lat/long is sufficient)
9.Site diagram or additional.welldetails: .
36.2466 N -77.8873 W 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
• Attach well construction record(s)if available.For multiple injection or non-water supply wells •
ONLY 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#: MW-11 . . abandonment to the following: .
•= Division of Water Resources,Information Processing Unit, '
13 1617 Mail Service Center,Raleigh,NC 27699-1617 • •
6b.Total well depth: (ft.) •
' IOb.For Injection Wells: In addition to sending the form to the,address in l0a
6c.Borehole diameter: 8.25 (in.) above, also submit one copy of this form within 30 days of conipletion of well '
• abandonment to the following:
6d.Water level below ground•surface: 5.30 (ft) Division of Water Resources,Underground Injection Control Program,
.
1636 Mail Service Center,Raleigh,NC 27699-1636
•
NA 10c.For Water.Supply&Injection Wells:In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
. 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): 3 • - - (ft.) abandoned.
• 6g.Screen length(if known): 10• (ft.) , ' ' ' '
• Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources . Revised 2-22-2016 .

WELL ABANDONMENT RECORD • For Internal Use ONLY: '
1
• 1,Well Contractor Information: WELL ABANDONMENT DETAILS;
Corey D: Futral 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 I GW-30 is needed. Indicate TOTAL NUMBER of
4300-B wells abandoned:
.
NC Well Contractoi•'Certification Number 7b.Approximate volume of water remaining in well(s): :(gal:) •
11
CATLIN-Engineers and Scientists FOR WATER SUPPLY WELLS ONLY: . .
Company Name
. 7c.Type of disinfectantused:
•• 2.Well Construction Permit#: NA .. .
•
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known .
• • 7d.Amount of disinfectant used: •
3.:Well use(check well.use):
Water Supply Well: re.-Sealing,materials used(check all that apply): .. •
• ❑Agricultural ❑Municipal/Public - ❑Neat Cement Grout P Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ' Residential Water Supply(single) ❑ Sand Cement Grout j ❑Dry-Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout 0 Drill Cuttings'
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry II-Other(explain under 7g)
•Monitoring ❑Recovery
•
Injection Well: .: 7f For each material selected above,provide amount of materials used:
• ❑Aquifer Recharge ❑Groundwater Remediation - Bentonite Pellets "' 25 lbs ,
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete . 12.5 Ibs
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description.of the abandonment procedure:
• ❑Geothermal(Closed Loop) ❑Tracer
❑Geotherniai(Heating/Cooling Return) 'oother(explain under 7g). Well abandoned in plaee.with hydrated bentonite
pellets to within 4 inches of surface and topped
01/-19/2023 Y€-�<�s._ . 9�f---F.
4.Date well(s)abandoned:
with concrete to existing grade. rw;:� ; ,w 4 •k, I;-1
5a.Well location: •
i.NCDEQ- Grandy Union 76 NA , JAN 2 ! 2023
Facility/Owner Name Facility lD#(if applicable) 8.Certification: L��( ?��4 t
• 6334 Caratoke Highway, Grandy, NC c7r.
�1 IF � 023
uc;ir: :l, : rh•. .�,f�a l r,..
• •Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Currituck 9912-72-6985 - •
By signing this form, I hereby cert fy that the well(s) was (were) abandoned in
County Parcel identification No.(PIN) accordance with 15,4 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 Iat/long is sufficient) I�
9.Site diagram or additional wellldetails:
3.6.2466 N -77.8873 ' ,,I, 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 WELL(S)BEING ABANDONED:
SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection ornon-watersupply wells
ONLY with the same construction/abandonment,you eon submit one form.
10a. For All Wells: Submit:this form within 30 days of completion of well
6a.Well ID#: MW-13 abandonment to the following:
• Division of Water Resources,Information Processing Unit,
15 1617 Mail Service Center,Raleigh,•NC 27699-1617
6b.Total well depth: (ft.)
lob.For Iniection Wells: -In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (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: 4.55 - (ft.) Division of Water Resources,Underground Injection Control Program,
. 1636 Mail Service Center,Raleigh,NC 27699-1636
NA 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
' . 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): 5 (ft.)
abandoned.
•
•
6g.Screen length(if known): 10 • (ft.)
• Form GW-30 • North Carolina Department of Environmental Quality-Division of Water Resource C Revised 2-22-2016
I

.
WELL ABANDONMENT RECORD For Internal Use ONLY:
..
•
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Corey D. Futral 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
4300-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN •Engineers and Scientists FOR WATER SUPPLY WELLS ONLY: •
Company Name
7c.Type of disinfectant used:
• 2.Well Construction Permit#: NA .. . .
List all applicable well construction permits(i.e.UIC,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 • . ' 0 Neat Cement Grout E Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout .0 Dry Clay
❑Industrial/Commercial • ❑Residential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
❑Irrigation . . - ' 0 Specialty Grout - 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry - U Other(explain under 7g)
•Monitoring ❑Recovery -
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge. ❑GroundwaterRemediation Bentonite Pellets - 25 lbs
❑Aquifer Storage and Recovery •❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete 12.5 Ibs
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
o Geotnermal(Closed Loop) ❑Tracer Well abandoned in place with hydrated bentonite
DGeothermal(Heating/Cooling Return) : ❑Other(explain under 7g)
• •
. pellets to within 4 inches of surface and topped
01/19/2023 •
4.Date well(s)abandoned: °.: + P
with concrete to existing grade. c;;y( ,F ; ,m� _
5a.Well location:
NCDEQ - Grandy Union 76 '• NA 2 r ����
Facility/Owner Name ' , Faciiity-lD#(if applicable) • 8.Certification: 7. 6/ c.. ,•, Air??r3y . 1.;r�lt
6334 Caratoke Highway, Grandy, NC . `J ►n,�, 1t�'n .
1 12fi20
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Currituck - .• - 9912-72-6985 •
By signing this form, I hereby cert5'that the well(s) tras(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
- and that d 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 lat/long is sufficient) 9.Site diagram or additional well details:
36.2466 N -77.8873 - �, 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 ; •
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/ahandonmerit,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-14 -abandonment to the following:. --
• Division of Water Resources,Information Processing Unit, '
•
6b.Total well depth: 15 (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: 8'25 (in.) above, also submit one copy of this form within 30 days of completion of well
. • abandonment to the following: , ,
4.52 Division of Water Resources,Underground Injection Control Program,
6ti.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
.
NA 10c.For Water Supply&Injection W
6e.Outer casing length(if known): (ft.) ells: 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): 5 - - (ft.) abandoned.
•
I . ..
6g.Screen length(if known): 10 • (ft.) - -
•
•
- .. . .
• .. .Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
• . .
.. . .. I •i .

t I
.. I i
WELL ABANDONMENT RECORD For Internal Use ONLY: a
1.Well Contractor Information: WELL ABANDONMENT DETAILS •
Corey D. Futral •
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
• 4300-B wells abandoned: ' i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATI_IN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY: .
•
Company Name - '
. 7c.Type of disinfectant used:
2.Well Construction Permit#: NA
•
List all applicable well construction permits(i.e:UIC',County,State,Variance,etc.)ifknown . •
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 D-Bentonite Chips or Pellets •
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay .
-' oIndustrial/Commercial . ❑Residential Water Supply(shared)' 0 Concrete Grout 0 Drill Cuttings.
•
0 Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry - IN Other(explain under 7g)
lMonitoring - ❑Recovery .
Injection Well: 7f.For each material selected above,provide amount of materials used:
•
. ❑Aquifer Recharge. ❑GroundwaterRemediation Bentonite Pellets • - 25 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test - ❑StormwaterDrainage' Topsoil ` 25 lbs
❑Experimental Technology, ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
•• •.❑Geothermal(Closed Lbop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ' Stick-up and PVC completely removed. Hole filled.
• . . in with'hydrated bentonite pellets. Soil to grade.
4.-Date well(s)abandoned: 01/19/2023 . . I, (,,.;a 1 ..° y ii,_gR
5a.Well location: JAN j 2023
NCDEQ - Grandy Union 76 NA •
2 if
Facility/Owner Name - Facility lD#(if applicable) 8.Certification: � � '+ {fli iif.:B;6C1 ?f^^,u h^tF�l.�ri;f
6334 Caratoke Highway, Grandy, NC U • 1t21/�03
Physical Address,City,and Zip . . Signature of Certified Well Contractor or Well Owner Date
• -Currituck 9912-72-6985 . : • • •
By signing this form, I hereby certify that the well(s)-was (were) abandoned in •
County Parcel Identification No.(PiN) • accordance with I5A 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: • •
• (ifwell field,one lat/long is sufficient) 9.Site diagram or additional well'details:
. 3.6.2466 N -77.8873 _ �, 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 WELL(S)BEING ABANDONED . SUBMITTAL INSTRUCTIONS '
Attach well construction record(s)ifavailable.Fot',nultiple injection or non-water supply wells --
ONLY with the saine construction/abandonment,you can submit one form.
. . - 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-15_ abandonment to the followin• g: • _ '
.. . . • - Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (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: 8.25 . (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: 5.88 (ft.) - - .Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
NA 10c.For Water.Sunnly&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) '
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment'to the coup_ty health department of,the county where
•
.
• 6f.Inner casing/tubing-length(if known): 5 • (ft.) abandoned. ,
6g.Screen length(if known): 10 (ft.) '
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
.. ...

WELL ABANDONMENT RECORD For Internal use ONLY:
- II '
• 1.Well Contractor Information: WELL ABANDONMENT DETAILSI .. '
1
Corey D. Futral 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
•4300-B ,•wells abandoned:
•
NC Well Contractor Certification Number - • 7b.Approximate volume of water remaining in well(s): (gal.)
• CATLIN.Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
•
2.Well Construction Permit ft: NA
List all applicable well construction permits(i.e.U/C,County,State,Variance,.etc)if known
7d.Amount'of disinfectant used:
- 3.:Well use(check well use): -
Water Supply Well: - 7c.Sealing materials used(check all that apply): •
•
' ❑Agricultural- ❑Municipal/Public - ❑Neat Cement Grout IJ• 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
❑Irrigation 0 Specialty Grout - ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ® Other(explain under 7g)
IMonitoring ❑Recovery
•
Injection Well: 7f.For each material selected above,provide amount of materials used:
•
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets "' 33 lbs
❑Aquifer Storage and Recovery LSalinity Barrier • - •
❑Aquifer Test ❑StormwaterDrainage Concrete 12.5IbS
❑Experimental Technology, ❑Subsidence Control
7g.Provide a brief description'of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Well abandoned in place.with hydrated bentonite •
❑Geothermal(Heating/Cooling Return) - ❑Other(explain under 7g)
- _ pellets to Within 6 inches of surface and topped
•4..Date well(s)abandoned: 01/19/2023 n � ���.
• with concrete to existing grade. 3>:>� i',�c _;
5a.Well location: •
NCDEQ= Grandy Union 76 NA ;A"d 2
023
Facility/Owner Name Facility.ID#(if applicable) • 8.Certification: cam; 'icte r ..._?^cr•, (Jr,!:
6334 Caratoke-Highway, Grandy, NC •• . . ;/'2.7'N21 23 •
•
Physical Address,City,and Zip • • Signature of Certified Well Contractor or Well Owner Date
Currituck -- • ' • ' . .99.12-72-6985 ' : •
By signing this form, I hereby ceriify 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 lat/long is sufficient) ,9.Site diagram or additional well
'details:
•
36.2466 N -77.8873 W . 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
Attach well construction record(s)if available.For multiple injection or non-water supply wells
ONLY 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.WeIIID#: MW-17 abandonment to the following: •
' Division of Water Resources,Information Processing Unit,
6b.Total well depth: 18 (ft.) ,1617 Mail Service Center,Raleigh,NC 27699-1617 ' '
• 10b:For Injection Wells: In'addition to sending the'form to'the.address in 10a
8.25 above,'also submit one copy of this form within 30 days of completion of well •
6c.Borehole diameter: (in.) .
abandonment to the following:
4.81 . Division of Water Resources,Underground Injection Control Program,
. 6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) 10c.For Water Supply&Injection 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 minty health department of the county where
•
. 6f.Inner casing/tubing,lerigth(if known): 3 • • (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources • Revised 2-22-2016 ' .
••
•
I

WELL ABANDONMENT RECORD For Internal Use ONLY:
r I
1.Well Contractor Information: • ' WELL ABANDONMENT DETAILS
CoreyD. Futral '
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
4300-B wells abandoned:
NC Well Contractor Certification Number - • 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name '. 7c.Type of disinfectant used: ':
• 2.Well Construction Permit#:• NA
List all applicable well construction permits(i.e.(IIC,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 ❑MunicipaUPublic ❑Neat Cement Giont - •-Bentonite Chips or Pellets
❑Geothermal'(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
[Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout . ❑Drill Cuttings
❑Irrigation ' .❑Specialty Grout t ❑ Gravel' '
Non-Water Supply Well: '. ❑Bentonite Slurry : . • Other(explain under 7g)
•Monitoring ❑Recovery .
Injection Well: 7f.For each material selected above,provide amount.of materials used:
•
❑Aquifer Recharge ❑GroundweterRemediation Bentonite Pellets ' - 33 lbs
. ❑Aquifer Storage and Recovery ❑Salinity Barrier .
' ' ❑Aquifer Test ' ❑Stormwater Drainage ; Concrete ; _ 12.5 Ibs
❑Experimental Technology- ❑Subsidence Control
7g.Provide a brief description of-the abandonment procedure:
••
❑Geothermal(Closed Loop) ❑Tracer Well abandoned in place with hydrated Bentonite
❑Geothermal(Heating/Cooling Return) OOther(explain under 7g).
pellets to•within 4 inches-of surface.and tgpp�ed.,�,„,
4.Date well(s)abandonear 01/19/2023 ' with concrete to existing grade. k 5 °I '1-^
5a.Well location: ' ' JAN 2 7 2023 .
NCDEQ - Grandy Union 76 NA _
' Facility/Owner Name Facility ID#(if applicable) 8. •Certification: - JYii' cilt t-'r+=^.,%/z,:'�L'rI
6334 Caratoke Highway, Grandy, NC - • . , • • . r • • -'^ �,Q:u�
;!� �� 1/27/2023 -
. Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
:Currituck • • 9912-72-6985 ' '
By signing this form, I hereby certify that the well(s) Was (were) abandoned in
• County Parcel Identification No.(PIN) ' 'accordance with.l5A NCAC 02C.0100 or 2C.0200 Well.Constritction 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 It/long is sufficient) 9.Site diagram or additional wellidetails: ••
36.2466 N -77.8873 _, ' 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS;
Attach well construction record(s)if available.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one for/.
lOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# IVIW-19 , abandonment to the following: '
• Division of Water Resources,Information Processing Unit, -
6b.Total well depth: (ft.)
18 ' 1617 Mail Service Center,Raleigh NC 27699-1617
. • lOb.For Injection Wells:'In addition to sending the form•to the address in 10a -
..25 above, also submit one copy of this form within 30-days-of completion of well
6c.Borehole diameter: - (in:)
abandonment to the following: I
6d.Water level below ground surface: 4.36 - (ft.) Division of Water Resources,Underground Injection Control Program, .
1636 Mail Service Center,Raleigh,NC 27699-1636
.
NA 1Oc.For Water Supply&Injection Wells: In addition to sending the-form to the
6e.Outer casing length(if known): (ft.) ' •
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): 3 (ft.) abandoned.
•
•
6g.Screen length(if known): 15 (ft.) ' •'
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY: ' I • .
1.Well Contractor Information: WELL ABANDONMENT DETAILS' .
Corey D. Futral •
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
4300-B ,• wells abandoned:
• 7b.Approximate volume of water remaining in well(s): (gal.) •
NC Well Contractor Certification Number 1
CATLIN Ehgineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name .. .
-: -. • • • 7c.Type of disinfectant'used:
2.Well Construction Permit#: NA ..
List all applicable well construction permits(i.e.UUC,County,State,Variance,etc.)if known
7d.Amount disinfectant used: : ..
3.Well use(check well use): .
' Water Supply Well: - - • ' 7• e.Sealing materials used(ch-eck.all that apply):
❑Agricultural' ❑Municipal/Public 0 Neat Cement-Grout IJ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑Dry.Clay .
•
' . ❑Industrial/Commercial . ❑Residential Water Supply(shared)' 0 Concrete Grout 0 Drill Cuttings
_❑Irrigation 0 Specialty Grout ❑ Gravel •
Non-Water Supply Well: 0 Bentonite Slurry IA Other(explain under 7g)
(Monitoring_ - ❑Recovery
Injection Well: - 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation ' Bentonite Pellets• "' 17 lbs
❑Aquifer Storage and Recovery . ❑Salinity Barrier '
• ❑Aquifer Test ❑StormwaterDrainage' Topsoil 15IbS
❑Experimental Technology: ❑Subsidence Control '
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer.. '
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g)
• PVC completely removed. Hole filled in with -
. hydrated bentonite pellets. Soil.to grade. •
01/19/2023 • 1i El)Z V
4.Date well(s)abandoned: •� " u�f
5a.Well location: ' '
NCDEQ= Grandy Union 76- ' NA L 'EAU 2 7 2023
Facility/Owner Name Facility ID#(if applicable) 8.Certification: cb, Gt/ .,-p-,a4l^,1 Pmc.-w,ng Lin::
6334 Caratoke'Highway, Grandy, NC- ) 5V1%11`7 2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Currituck' '9912-72-6985 '
By signing this form, I hereby certifi,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 let/long is sufficient) 9.Site diagram or additional well details: -
36.2466 N -77.8873 W.
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 WELL(S)BEING ABANDONED' SUBMITTAL INSTRUCTIONS '
Attach well construction record(s)if available.For multiple injection ornon-tvatersupply wells .
ONLY with the same consiruction/ahandonment,you can submit one form. '
_ . 10a. For All Wells: Submit this,form within 30 days of•completion of well
6a.Well ID#: MW-21 ' abandonment to the following:'
•
•
• • • Division-of Water Resources,Information Processing Unit,
•
12 • • 1617 Mail Service Center,Raleigh,'NC 27699-1617
6b.Total well depth: • (ft.)
10b.For Injection Wells: In-addition to sending the:form-to the address in 10a . '
6c.Borehole diameter: 8.25 • (in.) above, also submit one copy of•this form within 30 days of completion of well .
• . abandonment to the following:
1
3.02 Division of Water Resources,Underground Injection Control Program,
. 6d.Water level below ground surface: . (ft.)
• 1636 Mail Service Center,Raleigh,NC 27699-1636
NA 10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)' • •
• 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): 2 • (ft.) abandoned.
6g.Screen length(if known): 10- - (ft.)
' Form GW-30 '' North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016
. I

WELL ABA1\DONMI 1 RECORD • For Internal Use ONLY:
•
1.Well Contractor Information: WELL ABANDONMENT DETAILS •
I. i.
Corey D. Futral 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 jis needed. Indicate TOTAL NUMBER of .
wells abandoned: I -
4300-B
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers and SClentists • FOR WATER SUPPLY WELLS ONLY:
•
. ' Company Name
7c.Type of disinfectant used:
' 2.Well Construction Permit#: NA .
List all applicable well construction permits(i.e.UIC,County,Slate,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-Grotit . • 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 0 Drill Cuttings •
ID Irrigation . ❑ Specialty Grout ❑Gravel
• Non-Water Supply Well: • ❑Bentonite Slurry •Other(explain under 7g)
•Monitoring ORecovery - -
Injection Well: 7f.For each material selected.above,provide amount of materials used: • •
❑Aquifer Recharge. ❑Groundwater Remediation Bentonite Pellets ^' 17 lbs • .• .
•
❑Aquifer Storage and Recovery ❑Salinity Barrier • .
❑Aquifer Test ❑StormwaterDrainage Topsoil 15 lbs
' - , ❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer PVC completely removed. Hole filled in with '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g).
hydrated bentonite pellets. Soil to grade.-�°< FT' ; ;;��,.
4.Date well(s)abandoned: 0119/2023 - - v ti�y "' I
5a.Well location: JAN G .1 2lt23
NCDEQ- Grandy Union 76 NA - : •
?f,�:,ys,�3 kris
)n,C„,t:ws
Facility/Owner Name Facility ID#(if applicable) - .• 8.Certification: ,. --1. // v3;�_Q1uOG
•
TG•�c/
6334 Caratoke Highway, Grandy, NC ' - ;� 1/27/2023
. Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date -
-Currituck 9912-72-6985
By signing this form, I hereby cert 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 let/long is sufficient) -9.Site diagram or additional well details: ..
'36.2466 N -77.8873 - W.
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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS ' . '
Attach well constriction records)ifavailable.For multiple injection ornon-watersupplywells I, - •
ONLY with the same construction/abandonment,you can submit one form. - I.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# MW-23 abandonment to the following:'
Division of Water Resources,Information Processing Unit, •
6b.Total well depth: 12 (ft.)• - •1617 Mail Service Center,Raleigh,NC 27699-1617
•
10b:For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole.diameter 8.25 (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: 3.97 (ft.) . -Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I. .
6e.Outer casing length(if known):•NA (ft.) 10c.For Water.Supply&Injection 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): 2 • (ft.) abandoned. .
.
6g.Screen length(if known): 10 (ft.) -
.Form GW-30 . . North Carolina Department of Environmental Quality-Division of Water Resources . Revised 2-22-2016 ..
"

• WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Corey D. Futral . 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
4300-B wells abandoned:
•
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):' (gal.)
• CATLIN Engineers and Scientists • FOR WATER SUPPLY WELLS ONLY:
•
Company Name
. • 7c.Type of disinfectant used:
2.Well Construction Permit#: NA '
List all applicable well construction permits(i.e:UIC,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 g Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) '❑Residential Water Supply(single) ❑ Sand Cement-Grout 0 Dry-Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 0 Drill Cuttings
❑Irrigation . . .❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ® Other(explain under 7g)
(Monitoring • ❑Recovery
Injection Well: . . • . • : 7f.For each material selected.above,provide amount of materials used:
❑Aquifer Recharge .❑GroundwaterRemediation Bentonite Pellets' ' — 12.5.lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
•
❑Aquifer Test ❑StormwaterDrainage � Topsoil - 15 lbs
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description-of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ;
❑Geothermal(Heating/Cooling Return) OOther(explain under 7g) All of the PVC, well shield, and concrete removed.
Hole-filled in with hydrated bentonite pellets. Soil
4.Date well(s)abandoned:01/19/2023 to grade. . .a"„ .,L 6 t1",
5a.Well location: JAN 2 2n23
NCDEQ- Grandy Union 76 ' NA
Facility/Owner Name FacilityID#(if applicable) S:Certification: c. „tea I(13vi,7rtB,mn Pre- *^a ii j uri ..
6334 Caratoke Highway, Grandy, NC •' • . • .. a '"
Physical Address,City,and Zip ' • Signature of Certified Well Contractor or Well Owner Date
Currituck 9912-72-6985
• By signing this form, 1 hereby cert/'that the well(s) was (were) abandoned in
County Parcel-Identification No.(PIN) accordance with 15A NC.4C 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 lat/long is sufficient) '- 9.Site diagram or additional wellldetails:
36.2466 N, -77.8873 • W 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 WELL(S)BEING ABANDONED . SUBMITTAL INSTRUCTIONS •
Attach well construction record(s)if available. For multiple injection or non-water supply wells ,
ONLY with the same construction✓abandomnent,you can submit one form. - ' -
10a: For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-A . abandonment to the following: .
•
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 13 (ft.) • 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 8.25 .- (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: 5.96 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) - 10c.For Water.Supply&Injection 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): UnknOWn (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
• . .Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL
ABANDONMENT RECORD
WELL For Internal Use ONLY: •
1.Well Contractor Information: WELL ABANDONMENT DETAILS
'Core D. Futral '
y 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
4300-B • wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water'remaining in well(s); (gal.)
II
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
•
Company Name - '
• :• 7c.Type of disinfectant used:
2.Well Construction Permit#: •
NA
List all applicable well construction pennits(i.e.UIC,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 • ., ❑MunicipalPublic ❑Neat Cement Grout N Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) El Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
❑Irrigation El Specialty Grout ❑ Gravel '
Non-Water Supply Well: El Bentonite Shiny • Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: - 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge - ❑Groundwater Remediation Bentonite Pellets _ 12.5 lbs
❑Agtiifer Storage and Recovery OSalinity Barrier .
•❑Aquifer Test ❑StormwaterDrainage Topsoil 12.5lbS
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description-of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Well abandoned in place with hydrated bentonite
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g) '
• . - pellets to-within 6 inches of surface and-tapped,,, ;-,-r
01/19/2023 • .N �,�,1...M s 'V a_�.
4.Date well(s)abandoned: •" with soil to existing grade. ,
5a.Well location: JAN : ZUZ3
• NCDEQ - Grandy Union 76 NA • � ,r,� �_,� ���,;;
Facility/Owner Name Faciliry'ID#(if applicable) 8.Certification: \J �. DV.O uOiS
6334 Caratoke Highway, Grandy, NC !� 1/27/2023
•
• Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date . '
Currituck 9912-72-6985 .
By signing this form, I hereby certify that the well(s) was (were) abandoned in ,
County Parcel Identification No.(PIN) accordance with 15,4 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 lat/long is sufficient) 9.Site diagram or additional well'details:
36.2466 N -77.8873 • 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 WELL(S)BEING ABANDONED SLiBMITTAL INSTRUCTIONS
Attach well construction record(s)if available.For multiple injection or non-water supply wells
ONLY 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#: MW-B . . - abandonment to the following: ,
. Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 -
10b.For Infection Wells: In addition to sending the form'to the address in 10a
6c.Borehole diameter: 8'25 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
•
5.36 . Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: - (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
NA • 10c.For Water Supply&Infection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
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): Unknown (ft.) abandoned.
Unknown
6g.Screen length(if known): (ft.) .. ••
.Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
' .. .
i I

WELL ABANDONMENT RECORD For Internal Use ONLY: ,
I.Well Contractor Information: WELL ABANDONMENT DETAILS '
Corey D. FUtral 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
4300-B wells abandoned:
NC Well Contractor Certification Number • 7b.Approximate volume of water;remaining in well(s): (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY: •
Company Name
7c.Type of disinfectant used:
•
2.Well Construction Permit#: NA
List all applicable well construction permits.(i.e.UIC,Calmly,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 I Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 0 Drill Cuttings
El Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry "Other(explain under 7g)
"Monitoring - ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used: . .
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets - 12.5 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete 12.51bS
• ❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
• ❑Geothermal(Closed Loop) ❑Trat er Well abandoned in place with hydrated bentonite
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) .
pellets to Within 6 inches of surface. Conerete•to
the
• 01/19/2023 ,�s�� $ g �
4.Date well(s)abandoned: surface.
•
5a.Well location: JAN 2 7 2023
NCDEQ- Grandy Union 76 NA
• Facility/Owner Name Facility ID//(if applicable) 8.Certification: tfli'Gif`ilii 1�1C`
%11 '.c �•^;, ?flJl,�ift
6334 Caratoke Highway, Grandy, NC -• CJ ��--/ 1/27/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Currituck 9912-72-6985
By signing this form, I hereby certj'that the well(s) Was(were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A 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 1at/long is sufficient) . ' 9.Site diagram or additional well details:
• -36.2466 N -77.8873 - 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS •
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells .
ONLY 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#: MW-C : abandonment to the following: •
Division of Water Resources,Information Processing Unit,
•
6b.Total well depth: 13 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Injection Wells: In addition to sending the form•to the address in 10a
6c.Borehole:diameter:• 8.25 .(in•) above, also submit one copy of this form within 30 days of completion of well ••
abandonment to the following:
5.1 1 Division of Water Resources,Underground Injection Control Program,
• 6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 21699-1636 - •
6e.Outer casing length(if known):'NA (ft.) •
10c.For Water Supply&Injection 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): Unknown . (ft.) abandoned.
•
6g.Screen length(if known): Unknown (ft.) .
Form GW-30 . . North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD .: For Internal Use ONLY: . .
1.Well Contractor Information: • WELL ABANDONMENT DETAILS
Corey D. Futral 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 its needed. Indicate TOTAL NUMBER of
wells abandoned: I
4300-B t
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):' (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
I
.- Company Name
- 7c.Type of disinfectant used:
•
2.Well Construction Permit#: NA
List all applicable well construction permits.(i.e.UIC,County,State,Variance,etc.)ifknown i
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 j: 111:Bentonite Chips or Pellets
• ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑.Concrete Grout ❑Drill Cuttings' . •
❑Irrigation .. 0 Specialty Grout . , ❑ Gravel '
Non-Water Supply Well: ❑ Bentonite Slurry MI Other(explain under 7g)
(Monitoring ❑Recovery '_ ,
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation • Bentonite Pellets "' 88 lbs ,
❑Aquifer Storage and Recovery ' OSalinity Barrier
• ❑Aquifer Test ❑StormwaterDrainage Concrete 12.51bS
❑Experimental Technology ❑Subsidence,Control n '
7g..Provide a brief descriptio of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Well abandoned in place with hydrated bentonite.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
pellets to within 2 inches of surface. Concrete to the
4.Date well(s)abandoned: . . surface. 'L; ,p'tym; V ^_:;
5a.Well.location: • JAN
p ,n
21
NCDEQ- Grandy Union 76 NA �1
- Facility/Owner Name Facility ID#(if applicable) 8..Certification: t� G�7G"`� 'yt'Gi l p$i -n Pr+^ ;ri::nr !U/13:
6334 Caratoke Highway, Grandy, NC C `J L�U 7 %2�f2� 2'3
Physical Address,City,and Zip Signature of Certified Well Contractor or Well.Owner Date
• - •-Currituck 9912-72-6985 • :
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15,4 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 lat/long is sufficient) 9.Site diagram or additional well details: •
- • 36.2466 N -77.8873 W 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS '
Attach well construction record(s)if available.For multiple injection ornon-watersupply wells . - •
ONLY with the same construction/abandonment,you Can submit one form.
lOa. For All Wells: Submit this:form within 30 days of completion of well
6a.Well ID# TW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit, '
6b.Total well depth: 75 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Injection Wells: In addition to sending the,farm:to the.address in l0a '
12.25
6c.Borehole diameter: (in.) • above, also submit one copy of this form within 30 days of completion of well
- abandonment to the following: ,
6.42 -Division of Water Resources;iinderground Injection Control Program,
6d.Water level below ground surface: (ft.) .
1636 Mail Service Center,Raleigh,NC 27699-1636 .
• . . . h
6e.Outer casing length(if known): Unknown (ft) 10c.For Water Supply&Injection 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/tubieg•lerigth(if known): 70 -- (ft.) abandoned. .
.
6g.Screen length(if known): 5 (ft.) ' ' '
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 ' .

�9 pp, Jewry
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FORMER BULK a . _ , ,_ _.
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el A
Well (Type II)
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Well (Type Ill) `
0 Recovery Well
Location of Former
,. UST/AST System Ei -
Parcel Boundary a 22�,�77 n1�_ 2 �� ij��. �� ��my�Ma 1
aDIT ,L3-4,L�AI lMir.LUJl14111]bf "=1i idg§'�OW Eca Mia Tear offatuat
NOTES:
1. Well and UST/AST system locations were obtained from previous 50 25 0 50 100
reports prepared by other consultants and are approximate.
2. CNL= Could Not Locate i iiil Feet
PROJEC i TITLE FIGURE
GRANDY UNION 76
CiTLIN GCRAARNADT
NCHWY SITE MAP
Engineers and Scientists
INCIDENT NO. JOB NO DATE SCALE DRAWN BY/CHECKED BY
5726 220224 JAN 2023 AS SHOWN KMC/SJO