Dare_Well Abandonment_ (6)

WELL ABANDONMENT RECORD For Intemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Corey Gam Well 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
3027-A .s wells abandoned:
NC Well Contractor Certification Number c..0 Db.Approximate volume of water remaining in well(s): 1'S (gal.)
Ground Zero Environmental JAN 2 ® 202.1 FOR WATER SUPPLY WELLS ONLY:
Company Name Intcfm�l 7 ^r Un Je.Type of disinfectant used:
atia;,rl ; r...:�
2.Well Construction Permit#: N/A GMU'10
List all applicable well construction permits(i.e.U1C,County,Slate,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
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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) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation N Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat cement w/<5%bentonite powder 2.5 gal
❑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(explain under 7g) Remove the wells protective cover and well pad.Assure
the remaining pvc is 1'bgs. Fill the well with a cement/bentonite
4.Date well(s)abandoned: 12/19/2022 slurry from the bottom of the well to ground surface. Restore
5a.Well location: the surface with material that matched its surroundings and grass seed.
DCBR/ NAVFAC Oceana N/A
Facility/Owner Name Facility ID#(ifapplicable) 8.Certifiication:
1301 Navy Shell Rd, Stumpy Point, NC 27978 Ck. k AJC—,)
12/28/2022
Physical Address,City,and Zip Signature
Dare County 027733000 Certified Well Contractor or Well Owner Date
By sighing 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 miner.
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:
35.76210017 N -75.85421503 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
Aiiacli well constrnctioti records)ifavailable. For multiple it jeclion or non-water supply wells
ONLY with the swine construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MT-3/5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 18.18 bgS —(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:
UNKNOWN(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: 3.8 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NIA (ft.) 10c.For Water Supply&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
6f.Inner casing/tubing length(if known): N/A (ft,) abandoned.
6g.Screen length(if known): 10 (ft)
Fonn GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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