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Home My WebLink AboutCurrituck_Well Abandonment_20220826 � - R WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT DETAILS T 1 JL MUo4ky J Cy,rl t 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: NC Well Contractor Certification Number / 7b.Approximate volume of water remaining in well(s): L►&(gal.) Ferro voL Sera!a 4m j�#&O LL teti /y) LAC FOR WATER SUPPLY WELLS ONLY: Company Name 7e.Type of disinfectant used: 2.Well Construction Permit#: 3 1?S r !Q W W/K r Y w List all applicable well construction permits(i.e.U1C.Counry..State.Variance,etr..)if known 7d.Amount of disinfectant used: 3.Well use(check well use): Water Supply Well: 7e.Seating materials used(check all that apply): ❑Agricultural ❑M icipal/Public ❑Neat Cement Grout Q'<.tonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings ❑Irri ation ❑Specialty Grout ❑ Gravel Non-Water Supply Well: ❑ Bentonite Slum} ❑Otherixeitplatn tind'e�7g) ❑Monitoring G Recovery f..cw L.— Injection Well: 7f.For each material selected above,provide amount o e j s pse ❑A uiferRechar a ❑ ` GroundwaterRemediation „v0 4 U [oz2 ❑Aquifer Storage and Recovery ❑Salinity Barrier /2 7 uV rb �� lrxo;ir:;wi,3n Pmc?.,<;,„n3 Urt;3 ❑Aquifer Test ❑Stormwater Drainage ,.GbG o w ❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure: ❑Geothennal(Closed Loop) ❑Tracer � y ry� ❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under 7g) �tl.t pipe lie AT b e,16W q rade gog �A poured ? b ek-an4e down a e!roe 4.Date well(s)abandoned: � L' 1� ttA. l Sa.Well location: 4Cyle were �l.0 Facility/Owner Name Facility ID,'(ifapplicable) S.Certification: Zl?l 5ce�- IZ4 Coralls, , Z1927 —��,;,� l� 7 zoZ2. Physical Address.City.and Zip Signature ofCertified W Con ctor Sr Well Owner Date C.urrl' CIG O AOO[9067o00.5 By signing this form.I hereby certify that the well(s) was(were)abatdoned in County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner. (if well field one lat/long is sufficient) r 9.Site diagram or additional well details: 3/e /S 3� �,' N '1S• �Zt g W You may use the back:ofthis 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 wellconstrurtionrerord(s)ifavailahle.For multiple injectionornan-watersupplylVells ONLY with the same construcaion/abandemment.You ran submit one form. /�� 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#: NA- abandonment to the following: c Division of Water Resources,Information Processing Unit, 6b.Total well depth: `✓ (ft-) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Iniection Wells: In addition to sending the form to the address in I Oa 6c.Borehole diameter: AIA _(in.) above,also submit one copy of this form within 30 days of completion of well abandonment to the following: i I 6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program, ____ 1636 Mail Service Center,Raleigh,NC 27699-1636 rr'' 6e.Outer casing length(if known): IAA f�1M� (ft) 10c.For Water Supply&Iniecti I n 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. i 6g.Screen length(if known): 61 4aw N A) 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 Inform1ation: WELL ABANDONMENT DETAILS �r ` �,t'►�6'��1�/ eJiU �i�h 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: NC Well Contractor Certification Number , ' 7b.Approximate volume of water remaining in well(s): (gal.) J,oroV4 5er ae add CoasWchb►4 yW! FOR WATER SUPPLY WELLS ONLY: Company Name 35-y�oq W1_,rA� ;V T 7c.Type of disinfectant used: 2.Well Construction Permit#: W 1-` List all applicable well construction permits(i.e.UIC.County,.Slate.Variance,err..)if known 7d.Amount of disinfectant used: 3.Well use(check well rue): i Water Supply Well: 7e.Sealing materials used(check all that app )• ❑Agricultural ❑Municipal/Public ❑Neat Cement Grout WBentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) 56//Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings ❑Irri ation ❑ Specialty Grout ❑ Gravel Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g) ❑Monitoring ❑Recovery Injection Well: 7f.For each material selected above,provide amo UP f.!materials used: ❑Aquifer Recharge ❑Groundwater Remediation I go Ito -s e 1 []Aquifer Storage and Recovery ❑Salinity Barrier �a�— AUGi ❑Aquifer Test ❑StormwaterDrainage A 2 a 20�� _ El Experimental Technology ❑Subsidence Control r ❑ 7g.Provide a brief description of the abaadoa�165rtP?oaeclwte5'f�r,^,S,,y:r Uri, Geothermal(Closed Loop) ❑Tracer �;," ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) cwf Well Cd,$��i�4 W y; UT, (� q - ate( �`ill�d w/ f,s►!e p1 (hen&aefa Qrt-0 �\ 4.Date well(s)abandoned: I Z �� l Sa.Well location:�1 Jahrl 0 14&rfe✓ Facility/Owner Name Facility IDm(if applicable) S.Certification: IQ�fS $anclPrlJer led, Corolla . 47?4,7 '�„t/2- f� 7 'L7 Z41Z Physical Address.City.and Zip Signature of Certi ed W&Contractor or Well Owner Date C%rri fueK oy914 o9wo zgdda3 By signing this form.1 hereby certti I'bat the well(s) was(were)abandoned in County Parcel identification No.(PIN) accordance with 15A NCAC 02C:0100 or 2C.0200 Well Construction Standards 5b.Latitude and longitude is degrees/minutes/seconds or decimal degrees: and that a ropy of this record has been provided to the well owner. (if well field,one lat/long is sufficient) .,�p 9.Site diagram or additional well details: 3Lo Zq` 2 7„ N f7 S-�' 2 7,I W You may use the back of this page to provide additional well site details or well 1 abandonment details. You may also attach additional pages ifnecessary. CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS Attach well construction rerord(s)lfavailable.For multiple injection ornrm-water supply ivells ONLY with the same construcUonlabandonment,you ran submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#• ybOZ 6 abandonment to the following: Division of Water Resources,Information Processing Unit, 61b.Total well depth: 1�/� (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: ( (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: ` (fU) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): l (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): (ft.) abandoned. 6g.Screen length(if known): Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 WELL ABANDONMENT RECORD For Internal Use ONLY: I.Well Contractor Information: WELL ABANDONMENT DETAILS r �(i41 �/ 16 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 /�� wells abandoned: NC Welly Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.) Carom 5evvile urJ COKs wAgn UoC FOR WATER SUPPLY WELLS ONLY: Company Name 31 l�� W�� 7c.Type of disinfectant used: 2.Well Construction Permit#: List all applicable well ronstruction permits(i.e.UIC.County,.State.Variaw.e,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 apply): ❑Agricultural ❑MMJunicipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) I3Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay ❑industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings ❑Irri ation ❑Specialty Grout ❑Gravel Non-Water Supply Well: ❑ Bentonite Slurry Y Other(explain under 7g) ❑Monitoring ❑Recovery Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation ❑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 / ❑Geothermal(Heating/Cooling Return) ❑Other(ex n under 7g) Cw1 11'Ae rat we(( iry t1. and LQ'fotOP.G�• 4.Date well(s)abandoned: -7 ZZ �ZZ s, fi + ,S/a.WLell_location: vt r Facility/Owner Name _T— Facility ID;'(if applicable) S.Certification: G4TZ Ocean Pearl P, Corolla 7-2g41 Inbi'T51SUI O YiO-.tiC+`r1T1g Unf' �l � 4, pt'?iago' 1 - u e-- Physical Address,City.and Zip Signature ofOLfrtified Vifil Con for or Well Owner Date By signing this farm.1 herebv certify that the well(s) was(were)abandoned in County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner. (if well field,one lat/long is sufficient) 9.Site diagram or additional well details: �� WA N 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(Sl BEING ABANDONED SUBMITTAL INSTRUCTIONS Attach welt construrtion rerord(s)ifavailable.For multiple injection or non-avatersupply}cells ONLY with the same ronsirartion/abandonment,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, 61b.Total well depth: MtkKVwn (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Iniection Wells: In addition to sending the form to the address in I0a 6c.Borehole diameter: (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: (ft) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): (ft.) loc.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. 6g.Screen length(if known): Uf k4WV'r1 (fL) I Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016