Currituck_Well Abandonment_20230505

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Daniel C. Veltri 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owper personally abandoning well on his(her property) well construction/depth,only 1 GW-30 is needed Indicate TOTAL NUMBER of
NCWC 4368-A wells abandoned:
NC Well Contractor CenificadonNumber 7b.Approximate volume of water remaining In well(s): 1 (gaL)
Maupin Well Drilling FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:hypoch rite
2.Well construction Permit#:391928
List all applicable well construction permits CLe WC,County,State,Variance,etc.),ijlawwn
7d.Amount of disinfectant used: oZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout s BeWIonite Chips or Pellets
❑Geothermal(Heating(Cooiing Supply) sResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
Elfirigation ❑Specialty Grout ❑Gravel
Non-Water Supply Welh ❑Bentonite Shiny ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Well cutting full the Screen
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Poured Holeplug 4 Bag
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothemtal(Closed Loop) ❑Tracer
Clrorinated Well,FBI the screen with wag a0ing then filled�e carsug�q�Ho1ePI�R1'f"�yd
❑Geothermal(Heating/Coolin Return) ❑Other lain under 7 ) + T
4.Date well(s)abandoned:2 1 Apr 2023 MAY AY 0
t!5a.Well location: �Y�
Jacob Clarke � �
Facility/Owner Name Facility W#(ifappGcable) S•Certification:
521 Copper Garret Rd Moyock NC,27958 221 23
Physical Address,City,and Zip Sr ed Well Contra Dale
currituck 0010000015E0000 By signing this form,I hereby certify that the wells)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.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 Wang is sufficient) 9.Site diagram or additional well details:
36.501780 N —76.198082 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
Anachwellconshuctionrecord(s)ifavailable.Formultipleinjectionornon-ivatersupptyaells
ONLYwith the same construction/abandonment,you can submit oneform
10a For All Wells: Submit this faffi 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:28 (fL) 1617 Marl Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter.4 (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:5 (it-) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):24 (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
6t:Inner casing(tubing length(if known): (ff) abandoned
6g.Screen length(if known):28 (fL)
Form GW 30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016