Currituck_Well Abandonment_20230724

WELL ABANDONMENT RECORD For Internal Use ONLY:
WELL ABANDONMENT DETAILS
1.Well Contractor Information:
•T�' 1J.y J e�t il s h 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
�me(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW 30 is needed. Indicate TOTAL NUMBER of
Well Contractor Na
�,] i !a e wells abandoned:
A ` r 5 7b.Approximate volume of water remaining in well(s):_11 Y 4W 4 (gal.)
NC NC Well Contractor Certification Number
Caraya, SerdicE'.and (on5 �tc►1 �'�-�'
FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construrtion permits(Le.UIC.County..State,bnriam:e,eir.)ti(known 7d Amount of disinfectant used
i
3.Well use(check well use):
Fercial
ell: 7e.Sealing materials used(check all that apply):
❑//Municipal/Public ❑Neat Cement Grout
'I Chips or Pellets
ating/Cooling Supply) Asidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
mercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
7f.For each material selected above,provide t oG erla�,% e,E r
❑Aquifer Recharge ❑Groundwater Remediation �2
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
In�GiiY•w�o-tFtl t�L''.�:. �V6tk
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment ptrghk,lit%f-S(>,—a
❑Geothermal(Closed Loop) ❑Tracer + Ot 1 Vje I' 1; D del/
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 1� A
4.Date well(s)abandoned: 1 Y1 wt/� ��1��y(1�r'`�z 'll n 41 tt e &L
Ct � C4
5a Well location: � (r/Il4L/(k� G R11��esYyrA nd
,C�►ort�nas J (ri lb Facility/Owner Name Facility ID,'(ifapplicable)
S.Certification:
2b51 S m rtd6d4AW RA , Cora i k i Z7q tl ea Z3
Physical Address.City.and Zip Signature of grtified VVell Co ctor or Well Owner Date
ufrl 1DQ�U I A00004a001 By signing this farm.I hereby certifi,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(•opy of Ibis record hai C 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 well details:
You may use the back of this page to provide additional'well site details or well
N W 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 nr non-waier.supply wells
ONLY with the same ronstrurtfon/abandanment,you can submit one form.
t� 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• IAtI(� ywj/1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
61b.Total well depth: IA,tn✓W10wi- (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: yaw V4,to✓lk (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: ttK+,.�dWi/i (ft.) Division of Water Resources,Underground Injection Control Program,
.,_ 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): fAbLk tDWVJ (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): MI1k4tW4 (ft)
abandoned.
IA�CNOWV�
6g.Screen length(if known): (fL
) i
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Reso 4rces Revised 2-22-20I6