Currituck_Well Abandonment_20230526

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Daniel C. Veltri 7a.For Geoprobe/DPT or Closed-Loop Geothe I mat Wells having the same
Well Contractor Name(or well ownerpersonally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. indicate TOTAL NUMBER of
NCWC 4368-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Maupin Well Drilling FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type ofdisiaectantmsed: Hypochrite
2,Well Construction Permit#:394599
List all applicable nrll construction permits(e.UIC,County,State,Variance,etc.)ifhnoxm
7d.Amount of disinfectant used: oz
3.Well use(check well use):
Water Supply Welk 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout C Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) FResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout s Drill Cuttings
DIrrigation ❑Specialty Grout S Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRcmediation 3 Bags 1A Gravel pack Well cuttings
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 3 Bags of holeplug
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Choritnated the well then fill with 3 Bags of 1 A sand
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) '� c
u�
finished with well cuttings and holeplug ���-�...� ��`;; ��'
4.Datewen(s)abandnmed: 18 May 2023
MAY 2 5 2023
5a.Wen location:
Ronnie Stratton Ur;:i
Facility/Owner Name Facility W#(ifapplicabic) 8.Certification:
111 Cameron, Shawboro 27973 � 23
Physical Address,City,and Zip S' tum of vn� Dale
Currituck 00430000001 M00
By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NC,1C 02C.0100 or 2C.0200 Nell Construction Standards
and that a copy of this record has been provided to the well owner.
56.Latitude and longitude in degrees/urinuteslsernnds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.40696 N -76.06381 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
Amachwellconstmctionrecord(s)tfavailable.Formultipleitjectionornon-walersupplywells
ONLY with the same ronsovctionlabandanment,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:30 (ft.) 1617 Matt Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter.7 7/8 (ht) 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:6 (it) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2709-16%
6e.Outer casing length(if known): u n k (it-) 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
611 Inner casing/tubing length(if known): (fL) abandoned.
6g.Screen length(if)mown): (fL)
Form GW 30 North Carolina Department of Environmental Quality-Division of\Yatcr Rcsonms Revised 2-22 2016