Currituck_Well Abandonment_20230406

WELL ABANDONMENT RECORD For internal Use ONLY:
1.Well Contractor Information, WELL ABANDONMENT DETAILS
.lames maupin 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
NCWC 3517-A wells abandoned:
NC Well Contractor Certification Nmbw 7b.Approximate volume of water remaining In well(s):0. (gal:)
Maupin Well Drilling FOR WATER SUPPLY WELLS ONLY:
Company Name H ochdte
2.Well Construction Permit#:
391086 7�Typo of disinfectant used. yp
Lfst all applicable well consouctian permits(Le.WC,Cormty,Stag Variance,etc.)iflmorm
7d Amount of disinfectant used, oZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Publie ❑Neat Cement Grout s Bentonite Chips or Pellets
❑Geothermal(Heating(Cooling Supply) RResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑lodustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
DIrrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑AquifcrRecharge ❑GroundwaterRemediation 3 Bag DSI 1 A Sand
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 4 50 Ibs Holeplug
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
Ctrorirwted the well pound gravel pads down the well then fvlrthe well with hole l%M
❑Geothermal catinglCooling Retum) ❑Other(explain under 7g)
4.Datewell(s)abandoned: 17 Mar 2023
APR v G 2023
Sa.Well location:
Jeffrey Martin
Facility/Owner Name Facility W#(ifapplicable) 8.Ce cation:
125 Sand point Rd Knotts Island 27950 )
Physical Address,City,and Tip Signature o ertified Well Contractor or Well Owner Date
Currituck 0046000001 B0000
By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0I00 or 2C.0200 Nell 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 fiehl,one Wong is sufficient) 9.Site diagram or additional well details:
36.550015440 N -7600543410 �, 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 wellconstruetionrecord(s)ifavailable.Formultiple injection ornon-watersupplywells
ONLY with the same construction/abandonment,you can submit one form.
lba.For All Wells: Submit this form within 36 days of completion of well
6a.Well ID#• abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:27 (fL) 1617 Marl Service Center,Raleigh,NC 276994617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter.4 (m) 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: 13 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):21 (h) 10c.For Water Supply&Infection 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
6L Inner casing/tubing length(d known): ({t) abandoned
6g.Screen length('tf known):6 (fL)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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