Currituck_Well Abandonment_20230526 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James 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
N CWC 3517-A wells abandoned:-
NC Well Contractor Certification Number 7b.Approximate volume of water-remaining in well(s): (gal.)
Maupin Well Drilling FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type ofditiufectantused• Hypochrite
2.Well Construction Permit#:393048
List all appluable rrell construction permits(Le_WC.County,State,Variance,etc.)ifbwwn
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/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) SResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑lndushial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
[Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Rccovety
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 1 501b Hole plug
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothennal(Closed Loop) ❑Tracer chlorinated and gravity feed hole plug
❑Geothermal(Heatin CoolingRenun u❑Other(explain trader 7g)
.�17
4.Date well(s)abandoned-3 May 2023
Sa.Well location: MAY-2-6 2023
ED& May Brumsey
Facility/OwnerName Facility M#(ifappficable) 8.CertiGption: �i2r`6SiIT%l*" +�Pr.`-`' r!g Un
EArUBOIG
117 Puddin Ridge Rd. Moyock,27958
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Currituck 14B00000680000
By signing this form,I hereby certify that the rveff(s)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 bu/long is sufficient) 9.Site diagram or additional well details:
36.520486 N -76.175733 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 wellconstructionrecord(s)ifavailable.Formuldple injection ornon-watersupplynrlls
ONLY pith the same constructionlabandonment you can submit oneform. 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,
6b.Total well depth:7`5 (ft) 1617711 Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter•4 7/8 (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:6 00 Division of Water Resources,Underground Injection Control Program,
1636 Matz Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 1 1/4 00 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
6E Inner casing/tubing length(if known): (fL) abandoned
6g.Screen length(if known): (fL)
Forth GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016