Currituck_Well Abandonment_20230127 (2)

WELL'ABANDONMENT RECORD . For Internal Use ONLY:
• 1.Well Contractor Information: WELL ABANDONMENT DETAILS •
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Corey D. Futral .. 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor propert
y)(or well owner personally abandoning well on his/her • well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
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4300-B wells abandoned: ii
NC Well Contractor Certification Number 7b.Approximate volume of water'remaining in well(s): (gal.)
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CATL.I,N 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.NC,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 Grout G Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ' 0 Dry Clay
DIndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 0 Drill Cuttings
.❑Irrigation .. ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry iJ 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 . - .1", — 25 lbs . . .
❑Aquifer Storage and Recovery .- ❑Salinity Barrier •
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❑Aquifer Test ❑StormwaterDrainage Topsoil 25IbS
• ❑Experimental Technology " ❑Subsidence:Control • •
7g.Provide a brief description of the abandonment procedure:
• ❑Geothermal(Closed Loop) . OTracer - -
❑Geothermal(Heating/Cooling Return) f7Other(explain under 7g) Stick-up and 5 feet of PVC removed. Well abandoned
in place with hydrated bentonite pellets. Soil to- .
01/19/2023
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4.Date wells abandoned: g ��C ., , o ii s ¢ y` .
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5a.Well location: • JAN 2 7 2021
NCDEQ-Grandy,Union 76 NA • ... . •
Facility/Owner Name Facility ID#(if applicable) 8.Certification: '• ,r„a7,;^;1 Prim P•R'r,3:$3 tJru:
6334 Caratoke Highway, Grandy, NC f/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 tvell(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 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 consmuclion record(s)if available.For multiple injection or non-water supply wells
• ONLY with the sable construction/abandon/nen!,you can submit one form. '
IOa. For All Wells: Submits this form within 30 days of completion of well
6a.Well ID# MW-8 . . 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 Infection Wells:.In addition to sending the form to the address in 10a • •
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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:
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5:68 : Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: . .. . (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
• NA
6e.Outer casing length(if known): (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): 3 - (ft.) abandoned. .
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• 6g.Screen length(if known): 10 (ft.) .:
Form GW-30 ." North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016