Currituck_Well Abandonment_20230912

WELL ABANDONMENT RECORD For Imcmal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
N/A 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
Gordon Light- owner wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
N/A FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit ii: N/A
List all applicable well construction permits(i.e.UIC,County,State,Yariance,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 ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement�tlt_ ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) III Concrete Groot\ �
t '(� • r II Cuttings
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HIrri ation ❑ Specialty Grout D'Gravel
Non-Water Supply Well: ❑ Bentonite Slurry S E P 1 2 2023 ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each Kik£er1bP4 dtcQd bsV"� amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 60 LBS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Located well pvc (was buried by installer in 20222).
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
Severed pipe leading to well pump.
a.Date well(s)abandoned: 9/1/2023 Pulled out pvc sand spike apparatus (approx 17').
5a.Well location: Poured dry cement into hole and then capped off with wet cement.
southeast side of backyard n/a
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
Gordon Light Sept 6 2023
rga
Physical Address,City,and Zip Sature of Certified Well Contractor or Well Owner Date '
877 whalehead dr corolla nc 27927
By signing this form, 1 hereby certify that the well(s) was(were) abandoned in
Countye WuJ 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.
Sb.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:
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable. l br 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: 17 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (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: 15 (ft.) 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 Sunnly&Iniection 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): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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