Currituck_Well Abandonment_20230626

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
a`'uo-f sty J �U-sk 7a.For Geoprobe/DPT or Closed-1 lop Geothermal Wells having the same
Well Contractor Name(or ell owner personalty abandoning well on his/her property) well construction/depth.only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b.Approdmate volume of water remaining in well(s): tlK (gal•)
Caro Yet 5&-i-ce- '*4 caKsTr x'h1 n t1c FOR WATER SUPPLY WELLS ONLY:
Company Name �] Qr 7c.Type of disinfectant used:
2.Well Construction Permit#: 3/ D l z'
List all applicable well ronstruciion permits(ix.UIC.County.State.Variume,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 Wbentonite 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 ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: Cl Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑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 / t a!
[]Geothermal(Heatin Cooling Return) ❑Other(explain under 7g). rOUV1U1 /C3l�cV� l L°
. � .�,•i�;�:=:'� -=�..�� ,n��s i�slde �z �1`�e 7lrevt�luec�cap
4.Date well(s)abandoned: Z� Z023
l'
5a.Well location:
fkl'Sr6p�l r �.. �,�It:•_•f.�:F�d Ur"`
r e �ar�SB✓1 In�>„Irts.Et:�
FacilityFacili y/OwnerTme Facility I m P a6(ef`�— 8•Certification:
I T Z '5aAd CQd1et' < is d ict- 2 M-1 �^ 20Z
Physical Address.City.and Zip Signature of tertificeVell Contractor or Well Owner Date
c,-rr•l k elr 6f?*00g met 10003 By signing this form.I hereby certtfi 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 owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficief t) ( r t 9.Site diagram or additional well details:
1p4 Z /lo t 33 N ?S :�-I Z,& 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 construction rerord(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same ronstrurttiio�n�lya(bandonment,you ran submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#. /VPi abandonment to the following:
Division of Water Resources,Information Processing Unit,
I`r 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: A)
)� 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: IV I (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 !�� (fL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
/
6e.Outer casing length(if known): /" (fL) 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/tubingif known): v/A A) abandoned.
length(�
A / I I
6g.Screen length(if known): aV 1� A)
Revised 3-32-3016
Form GW-30 - North Carolina Department of Environmental Qualiry-Division of water Resources

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Permit: 363931 Currituck J '
WELL!PERMff"'-
PIN: 087AO0100SM0003
Aeaebw:tr•REG�dXAL11CALTy SEPyjCrs
Fainters In Pdbk Rich
Owner: Applicant:
LODGE DAVID&KRISTEN LODGE DAVID&KRISTEN
6049'WALKING PATH LN 6049 WALKING PATH LN
MIDLOTHIAN,VA 23112 MIDLOTHIAN,VA 23112
Location:
2278 SANDPIPER RD
564, 3 19
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AND REPAIR+4R> N
�AIE1,L I16iUS7r f3E INSTALLED SY A NO QMTIMEQ V4tLL DRW-M. . y
•'+IYl L PERM11'Mt,IST SE ON LCW3ATION dUR&O RLLPERIQ0 -
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Permit By: Date: 06110/2022
obbs,Joe
Certification By: Date:
I ,
Construction has been completed, a Residential Well Construction Record Forrp GW-1a has been
submitted and inspections have been completed 1n accordance with 15A NCAC 02C.D300.