WQ0002284_Engineering Certification_20061208

i
12- 8-06;18:25 ;B P O ;252 261 1760 # 1/ 3
:x ilp
r. s.
FAX TRANSMITTAL
TO: Robert Tankard
cc: Jim Coleman; Bill Freed
FAX No.: 252-975-3716
FROM: Mark Bissell
DATE: 12-8-06
# of Pages: cover + 2
■ry■■■■■■rr■r■■■■■rrr■■■r■■■■■■■■■■■■■■■■■r■■■■■r■■■■■r■■■rr■■■■■■■■■■■■■■■■■■1
COMMENTS: Robert, I understand from Jim Coleman that you will be
making a visit to the Kinnakeet Shores VVWTP on Monday. I also understand
that there may be some question concerning the status of the operational
certification. I was not able to reach you today to. discuss the situation, but I
did speak with Bill Freed, who indicated that he is planning to meet you on
site sometime Monday. I will be in Currituck from 10:30 until around 1:30
Monday afternoon, so the earliest I would be able to arrive at Avon would be
around 2:30.
I am attaching a copy. of the partial certification that was prepared in April,
2005 for discussion. This certified the system for initial operation up to 92,500
GPD. It is my understanding that the seasonal flow has not yet approached
this number, but we are in the process of updating the certification based on
several additions to the irrigation system that have been completed since the
original certification. A preliminary review of this as -built information
indicates that the system is now capable of handling about 50% more than
indicated in the initial calculations. This updated certification will be
'finalized when I have verified all of the information.
I can be reached in the office Monday morning until 10:30 at [phone],
and by cell phone after that at (252) 202=1215. Thanks.
P.O. Box 1068 ■ 3512 N. Croatan Hwy. ■ Kitty Hawk, NC 27949
252-261-3266■ Fax: [phone] E-mail:bpg®bissellprofessionalgroup.com

12- 8-06;18=25 ;B P O
;252 261 1760 # 2/ 3
Permit No. WQ0002284
ENGINEER'S CERTIFICATION
X Partial
Final
E$SIUfV:4L` :GEiO:LJP,
I, Mark S. BisselI as a duly registered Professional Engineer in the State of North
Carolina, having been authorized.to observb t)eriodically the construction of the project,
K Ur nnalceet shores, Dare County' North Carolina
for the Permittee hereby state that, to the best of my abilities, due care and diligence was
used in the observation of the construction such that the construction was observed to be.
built within substantial compliance and intent of this permit, the approved plans and
specifications, and other supporting materials, with the following exceptions:
1. This is a partial certification covers the wastewater treatment facility and the first
portion of the reuse'irrigation disposal system- The irrigation system is in service
in Phases 9, 10, 11, 12, 17 and 18, covering an area (subject to final verification
of each spray head through as -built survey, in progress) ofapproximately 346,573
square feet, which equates to a disposal capacity of approximately 92,540 gpd at
the approved application rate of 3.1 inches per week.
2. Level gauges need'to be installed in the ponds within 60 days of start-up,
3. The perimeter fencing needs to be installed around the disposal site,
4. The pond banks need to be seeded and stabilized.
5. Modifications were made to the location and orientation of some of the ireatment
units with respect to one another in order to accommodate a ventilated pre-
engineered enclosure, in lieu of a control building that housed only the blowers
and disinfection equipment. Modifications are shown on record drawings to be
submitted under separate cover.
6. The groundwater lowering pump system has not been made operational at this
stage (not needed up to 151,000 gpd).
7. Irrigation is not being utilized initially around the wastewater disposal site
property line (zone Al) due to the potential for overspray.
P.O. Box 1068 a 3512 N. C roatan Hwy. ® Kitty Hawk, NC 27949
252-261-3266 a Fax: [phone] ® E-mail: [e-mail]

12- 8-06;18:25 ;B P O
;252 261 176O # 3/ 3
8.. -Modifications were made to the irrigation controllers in order to reduce wiring
and to improve reliability.
9.. Addition of intake manhole and valve on'irrigation suction line for maintenance
of foot valve; addition of self-cleaning intake screen.
10. The bathroom needs to be completed.
11. Anoxic detention time was increased slightly at the expense of aeration detention
time, as discussed with DWQ during plant fabrication. The final numbers are:
anoxic: 2 @ 26,340 gallons;. aeration: 47,645 + 125,000 + 172,645 = 345,290
gallons.
12. Piping refinements were made during constructio ' as indicated on the record
drawings.
13. Relocation of irrigation pump and controls to inside plant enclosure to improve
operations and maintainability of the irrigation system.
14. Refinements to alignment of irrigation piping to preserve vegetation; use of
flexible tubing.to provide ability to make adjustments to spray heads around
driveways, etc. An as -built survey is in progress to pinpoint the location of each
irrigation head in the subdivision.
15. Relocation of access ladder to between main plant and external clarifier for
improved accessibility.
16. The traveling bridge filter area was increased From 348 square feet to 360 square
feet (30 cells), which decreases the flow rate from 0.7 to 0.675 gpm / sq. fL
17. The effluent valve chamber was modified for dual control valves in lieu of a
single valve.
18. It wAs necessary to modify the 5-day return pump tank from a 3,500 gallon PT-
168 to an 8-ft. diameter 4,100 gallon tank.
19. The stand-by generator was relocated to the interior of the enclosure, and vented
to the outside
Signature
401
RegistrationNo._,/'U?c Z

12/11/2006 17:57 2529953839 KINNAKEET SHORES INC PAGE 01/13
Outer Banks Assodate LLC
Date: 1 1 Ll
Fax Number. ��.52_ G`1 S —
From: Jim Coleman
Project maoagrr
Number of Paws (Thchi&og Cover Sheet): AL3
mum
Outer Blanks KinuAeet Inc.
PO Box 786, Avon, NC 2791.5
F mail:.um@kmnakectshoMsresortcorg
Phone: [phone]
��a^" Fax: [phone]

12/11/2006 17:57 2529953039 KINNAKEET SHORES INC PAGE 02113
North Carolina - Departr=t of Enviroament and Natural Resouroos - Division of Water Quality - Uroundwater Station - 1636 Mail
Service Center - Raleigh, NC 27659-1639 - Phone No. [phone]
WELT ABANDONMENT RECORD WELL CONTRA,Cx'OR
WV1, CONTRACTOR C1 RT1< QA'TION 0 aOJ-7
1. WELL USE (Check Applicable Box): R.esidButial ❑ Municipal ❑ Industrial ❑ ,A.gzicultural © Monitoring
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,•List Usa:
2, WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest'Town: �i+�rP i �5 County_--
(R.oad Name and Nwnbcr, Coma:murclty, Subdivision. , Lot No.
• • • /J �r . t/ !/.ill. - �J�. 3
S. TOPOGRAPHY: draw, slope, hilltop, vaIley, flat
(circle one)
6. TOTAL DEPTE: t DIAMETER, g2
7. CASING REMOVED:
l3'
$. DZSINk'ECTION: � o
(Amount of 70% hypocblorite used:)
9. SEALING MA.TEMAL:
1Ve_at Cement find_ .ement
bags of cement _ bags of cement
gallons of water ^:_ gallons of water
other
Type material
Amount
Quadran& No.
WELL DI .GRA.M: Draw a detailed sketch of the
wall sbowiag total dep* depth and diameter of
ecmens remaining in the well, gmvol,iatmvRL
intervals of casing perforations, and depths and
types of U Materials Used.
11. DATE WELT ABANDONED
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided tq th ll ow:gX,
Signature of person abandoning the
— j a —C, 5—
WELL LOCATION: Draw a -location sketch on the reverse of this sheet, showing the direction and distance
of tht well to at least two (2) nearby roferenee points such as roads, iniarseotiona and
streams. Identify roads with State Highway road identification number, .
Submit original to the Divisicm of Water Quality, Groundwater Section, one copy to the owner, within 30 days
from completion of abandonment.
OW-30 Revised 12199

12/11/2006 17:57 2529953039 KINNAKEET SHORES INC PAGE 03/13
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwatcr Section - 1636 Mail
Scrvico Center - Raleigh, NC 27699-1639 - phcme No. [phone]
vMLL ASANDONMMNT PXcO" WELL CONTRACTOR
WELL CON TRACTOR CERTIFICATION #
1. WELL USE (Check Applicable Box); Rcsidcntial ❑ Municipal ❑ liadn&trial Cd Agrioultural ❑ Monitoring t1
Recovery © Heat Pump Water Injection ❑ Other ❑ If Other, List Uso:
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town-, J�U67 -- _ County F'
(Road Name and Number, Community, Subdivision, Lot No.)
5. 'T'OPOGRAFXY: draw, slope, bllltop, valley, flat
(atrcle one)
6. TOz'AL. DEl'ul: /,2 - - DIA1v1ETER--
7. CASING REMOVED:
fell tl� un�=
rK;2 1.
S. DIS2,TFECrION: '/'_ e a
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
hL%1LCkU ,sand C'cmant
bags of cemcnt i bags of cement__
gallons of water gallons of water
OtheL
Type materi
Amount
10. EXPLAIN METHOD EMML.A.CEM= OF MATERL&L.
11. DATE WELL ABANDONED 0'.3� ^ °
Quadrangle No.
WELL DIAGRAM; Draw a debuted sketch of the
well showing total depth, depth and diameter of
sCreeus reuia.Wing to the well, gravel interval,
intervals of casing perforations, and depths and -
types of fill materials used.
I do hereby certify that this well was abandoned in accordance yth 15A AC 2C, well construction
standards, and that a copy of the record has been provided t the finer.
Signature of person abandoning the well Date_
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance.
of the well to at least two (2) noarby refereuce points such as roads, intersections a -ad
streams. Identify roads with State Highway road identifioation numbers.
Submit original to the Division of Water Quality, Groundwater Section, one copy to the owner within 30 days
from completiort of abandonment.
GW-30 Revised 12/99

12/11/2006 17:57 2529953839 KINNAKEET SHORES INC PAGE 04/13
North Carolina - Department of Environment and Natural Resources - Divisiou of Water Quality - Groundwater Section - 1636 Mall
Service Center - Raleigh, NC 27699-1639 - Phone No. [phone]
NV LL ABA.NDONMENT SCOW) WRLL CONTRACTOR
WELL CONTRACTOR CERTIFICATION # ,:21) P'7
1. WELL USE (Check Applicable Box). Residential ❑ Municipal ❑ Industrial ❑ ,A.gvicultural t ] Monitoring
Recovery El Heat Pump Water Injection ❑ Other Q I£ Qther, List Usc:
2. WELL LOCATION: (Show a sketch of the location on back of form.) ��
Nearest Town: ,.4�ib �rJ County laV. e'
(Road Name and Number, Community, Subdivision, Lot No.) Quadrangle No.
3. OWNER:f.�Srs�ivS.rf���
4. ADDRBSS.&641Z 79'6
S. TOPOGRAPHY- draw, slope, hilltop, vallcy,CIat-
(circle one)
6. TOTAL DEPTH: J ? DL M>✓TER o� r
7. CASING REMOVED:
meter
8. DISTNWECTTON: �j 4
(Axnount of 70% hypochlorite used:)
9. SEALING MATERIAL:
at S,ond-cgx end
bags of cement bags of cement
gallons of water- gallons of water
Qtl=
Type material _
Amount
10. =LAIN METHOD ENSLA.CEN= OF TERIAL.
11. DATE WELL ABANDONED cP'~,4e -4 Sf
itrP,LL DIAGRAM: Draw a detailed sketch of the
w011 showing total depth, depth arzd diameter of
screens remaining In the well, gravel interval,
intervals of casing perforations, and depths and
types of fill watetials used,
'341'0e� .
I do hereby certify that this well was abandoned in accordance with I SA. NCAC 2C, well construction
standards, and that a copy of the record has been provided t the weer
Signature of person abandoning the well '5�Date a -'e s f
WELL, LOCATION: Draw a location sketch on the reverse of this sheet, showitlg the direction and distance
of the well to at least two (2) ncarby reference points such, as roads, intersections and
streams. Identify roads with Statc Highway road identification numbers.
Submit original to the Division of Water Quality, Groundwater Section, one copy to the owner within 30 days
from completion of abandonment.
OW-30 Revised 12199

12/11/2006 17:57 2529953839 KINNAKEET SHORES INC PACE 05/13
Nortb Carollns - laopertrnent of Environment and Natural Resources - Division of Water Quality - (3romd.water Section - 1636 Mail
Service Center - Raleigh, SIC 27699-1639 - Phone No. [phone]
NVELL ABANDONMENT RECOP.J] WXLL CONTRACTOR %.yam 5�
WELL CONTRACTOR CER'Z'T1;'TCATION # c,209-7 _
1. WELL USE (Check Applicable Box): Rosidetrdal ❑ Municipal ❑ Tzdustcial ❑ Agricultural © Monitoring l�
Recovery D Heat Pump Water Injection 0 Other ❑ If Other, List Usc;
2. WELL LOCATION: (Show a sketclb of the location on back of form.)
Neaxest Town: t'lpN County 22zyzg _-
(Road Name and Number, Community, Subdivision , Lot No.) Quadrangle No,
3. OWNER12 � lcs' e<i- '9Mac
4. ADDRESS'Aa-.'
5. TOPOGRAPHY: draw, slope, hilltop, valley, fiat
(circle one)
6. TOTAL DF,7M: // DIAMETER
7. CASING REMOVED:
,fcict ski z> s
S. DISINFECTION: 4!2 02
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cem=1 Sand cm .n
bags of cement % bags of cement___ .
gallons of water — _ gallons of water
Other
Type material
Amount -
10. EXPLAIN M��jj �THOD ENIPLACI~I= O MATERL.4L.,
11. DAB WELL ABANDONED'—p
WELL DIAGRAM: Draw a detailed sketch of the
well showing total depth, depth and. diai=ter of
scraew remalaing in the well, gavel interval,
intervals of casing perforations, and dopths and
types of fill materials used.
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provide owner
Signature of person abandoning the well
WELT. LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby rafemnce points such as roads, intersection and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Groundwater Section, one copy to the owner within 30 days
from completion of abandonment.
CAW-30 Revised 12/99

12/11/2006 17:57 2529953039 KINNAKEET SHORES INC PACE 06/13
North Carolina - Depa=ont of Fnvlror'm=t and Natural Resources - Division of Watcr Quality - Groundwater Section - 1636 Mail
Service Center - Raleigh, NC 27699-1639 - Phone No. [phone]
WELLABANDONMMNTRECORD warirL CONX ACTOR `,9.- WELL CONTRACtOR CTiI;t'I-ICATTON
1. WEL L'USE (Check Applicable Box): Resideutial El Mif xdcipal ❑ Industrial ❑ Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Xnjectiou ❑ Other ❑ If Other, List TJsc:
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town: 141-14,10 County ,0 '---
(Road Name and Numb(tr, Community, Subdivision , Lot No.)
3. OWNER: 4'�- iO'V'6-'S' .rs-0 C' /-�
4. ADDRES5:6)-�7(,'��'%n �4�1y i7 L
5, T0P0GP ,=Y: draw, slope, hilltop, valley flat
6. TOTAL DEPTH: (circle ono)
DIAMETER
7. CASING REMOVED:
f.�at slraxuatei
S. DISINF1rCIJON: oZ'
(Amount of 70% hypoehlorite used:)
9. SEALING MATERIAL:
jyg. k Csment
bags of cement %
gallons of water
Type material
Amount
Sand Qpn=
bags of cement
gallons of water
�� r conmr0e)"XV010• •
11. DATE WELL AJ3AND ONED _ � — 30 - Of -
Quadrangle No.
WELL DIAGRAM: Draw a detailed sketch of the
well showing total depth, depth and diameter of
screens zerr,.aining in the wall, gravel interval,
intervals of casing perforations, and depths and
typca of fill Materials used.
I do hereby certify that this well was abandoned in accordance with 15,A. NCAC 2C, weU construction
standards, and that a copy of the record has been ovided the vy� owner.
Signature of person abandoning the well Date 3ro
YELL LOCATION: Draw a location sltoteh on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby referenoe points such as roads, intorsectioos and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Groundwater Section, one copy to the owtler wid-in 30 days
from completion of abandonment.
GW-30 Revised 12/99

12/11/2006 17:57 2529953839 KINNAKEEf SHORES INC PAGE 07/13
North Cerolina - Depmtment of Environment aid Nantral Reaourcas - Division of Water Quality - Groundwater Section - 1636 Mail
Service Center - Raleigh, NC 27699-1639 - Ph= No. [phone]
WELL A.BANl]ONMINT RECORD Wli!T•i, CONTRACTOR
WELD CONTRACTOR CLRTMICAVON
I. WELL USE (Check Applicable Box): ReaidEntial ❑ Minaicipal ❑ zndustrial ❑ Agriculttttal ❑ Manitoring lf(�
Recovery ❑ Heat P=T Water Woction O Other ❑ If Other, List Me:
2, WELL LOCATION: (Show a skotch of the location on back of form.)
Nearest Town:--_-- - __ P_.[� -_ _. _ County _-__ J9'y,y �
(Road Name and Number, Community, Subdivision, Lot No.)
3. Zle. f
4, ADDRESS:
5. TOPOORAPHY: draw, slope, hilltop, valley, flat
t (circle one) J/
6. TOTAL DE=- DLAME' ER .
7. CASING REMOVED:
feeAt diamatss
8. DISINFECTION; d __
(Amount of 70% hypoohlorite used:)
9. SEALING MATERIAL:
NAat_Cmr Sand Cem"
bags of cement _-_-% bags of cement_
gallons of water:_ gallons of water
Other
Type material _
Amount
11. DATE WELL ABANDONED
Quadrangle No.
WELL DIAGRAM; Draw a detailed sketch of the
well showing total deptb, depth and diameter of
screens :rcxrmbnJng in the well., gravel interval,
intervals of casing perforation+, and depths and
types of fall materials used.
I do hmby certii that this well was abandoned in accordance with 15A NCA.0 2C, well construction
standards, and that a copy of the record has been provided the M er.
Signature of p=on abandoning the well Date 0 -
WELL LOCATION; Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intermctiou and
streams. Identify roads with State Highway road identification, numbers,
Submit original to the Division of Water Quality, Groundwater Section, one copy to the owner within 30 days
from completion of abandonment.
GW-30 Revised 12/99

12/11/2006 17:57 2529953039 KINWEET SHORES INC PAGE 08/13
North Carolina - Dcpanment of Environment and Natural Resources Division of Water Quality - Groundwafor Section- 1636 Mail
Service Center - Raleigh, NC 27699-1639 - Phone No. [phone]
WELL ABANDON1 MNT RECO" WELL CONTRACTOR
WELL CONTRACTOR CERTMCATION
1. WELL USE �Chcek Applicable Box): Residential ❑ Municipal ❑ Industial ❑ Agricultural ❑ Monitorl ng 4]-'
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2, WELL LOCATION: (Show a sketch of the location ouback of form.)
Nearest Town: }L//LCl County (a —el —
(Road Name and Number, Community, Subdivision , Lot No.) Quadrangle No.
3. OVJNEP�G9NiE'1550 L' -
4. ADDRESS:•
S. 'TOPOGRAPHY. draw, slope, hilltop, valle , a
r (circle one)
6. 'TOTAL i)EPTH: DZkNfRIM
7. CASING REMOVED:
£eAt diameter
42 • _ , a
S. DISINFECTION: c o z -
(Amount of 70% hypochlorite used:)
9. SEALING MATEMAL,:
Neat CcmG Sand r,&013t;
bags of cement / bags of cement__
gallons of water_,! — gallons of water
Type material
ArAnourlt
10. ENPLAIN METHOD EMPLACI~lv>`ENT OF'TERIAL.
11. DATE WELL ABANDONED
WELL DIAGRAM: Draw a dctailed sketch of the
well sbowing total deptb, depth and diameter of
screens retraining in the wall, gravel interval,
intervals of casing perforatiorjs, and depths and
types of fill materials used.
I do hereby certify that this well was abandoned in accordance with 1 SA NCAC 2C, well construction
standards, and that a copy of the record has been provided t the we wncr.
Signature of person abandoning the we11 Dam
WELL LOCATION: Draw a location sketch ou the reverse of this sheet, showing the direction and distance
Of the well to at least two (2) nearby reference points such as made, intersections and
streams. Identify roads with State highway road identification numbars.
Submit original to the Division of Water Quality, Groundwater Sectiox),, one copy to the owner within 30 days
from oompletion of abandonment.
GW-30 Revised 12/99

12/11/2006 17:57 2529953839 KINNAKEEr SHORES INC
- North t,,,arolina,
Department of Envimnment, Health, & Natural. Resources
Division of Environmental Nf nagement
Groundwater Section
P.O. Box 27687 - Raleigh, N.C. 27611.
WELL ABANDONMENT
CONTRACTOR �?l �t/� i drU _ ._._ ._ ..... .... . .... ... RE*. N4.rn,0�p'
PAGE 09/13
L WELL LOCATION: (Show, a skz,Kch or the location on back of for ti-0
Nearest Town: County —1=�
Community, SubdivWom Lot No.) Quadrangle No.
i
4, TOPOGRAPHY : draw. slope, hilltop, valley,,�flat
5. USE OF WELL -,; _DATE: Vl!� �
,I
a TOTAL DEPI y� _ DIAMETER
7. CASING REMOVED:
8. SEALING MATERIAL:
Neat cement
bags of ceulent
gals. of water
diamete
.12 r/
yds. of sand
gals. of, water
material . lwo CI
Amount
WELL DIAGRAM: Draw a detailed sketch of
the well showing total depth, depth and dia-
meter of screens, ret=tning in the well, gravel
interval, intervals of casing perforations, and
depths and types of U materials used.
A)U f fOr N j o
>OR
/ E � "�''AA ry //ta 1;*%) vc j
9. EXPLAIN METHOD EMPLACE EZ7 OF MPS
s
I doh certify that this weIl abandonment record is true and exact.
SigrQ tune or Contractor or Agent Date 2!22"[B +O
WFT,T• LOCATION: Draw a location sketch on the reverse of Oils sheet, showing the direc-
UOn and distance or the well to at least two (2) of zarby reference potnts
Such as roads, intersections and stxecar>9. Identify roads with State High
way road idend5mLion numbers.
Submit original to the Division of EnvironMental Mar}agement, one copy to the Driller,
and one copy to the owner.
GW-30 FzW--ed 3/8/90

12/11/2006 17:57 2529953839 KINNAKEET SHORES INC PAGE 10/13
North Carolina
Depaartrnent of Environment, Health, & Natuaural. Resources
DM-s.lon of Environmental Management
Groundwater Section
P.O. Box 27687 - Raleigh, N.C. 27611
1. WELL LOCATION: (Show a sImAch of the location on back of form.)
Nearest, Town: County a �
4. TOPOGRAPHY : draw, slope. hilltop, valley. flat
5, USE OF WELL VDATE47 ` -Oct
6. TOTAL DEPTH: --DIAMETER: '
7• CASING REMOVED -
Ltd diarnete
/o 1 .-1 //
S. SEALING MATERTA .
lit —cement sand Qmjmt
bags of eernent —.. _ bags of cement _
gals. of water yds, of sand
gals. of 'water
adrang a No.
L DIAGRAM: Draw a detailed sketch of
well showing total dcpth, depth and dia-
T of screens remaining in the well, grovel
val, intervals of casing perforations, and
hs and types of fM materials used.
1-16 14VI'v
V
9. Ex� METHOD EMPJ ACFIY EN!' OF MATEPIP?I,
I do hereby certify JVnt this well abandonment record is true and exact.
Signature of Contractor or AgentIen « `G
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direc-
tion and distance of the well to at least two (2) nearby reference points
such as roads, irrtcmections and streams, ldentiPy roads with State High
way road identification numbers.
Submit original to the Division of Environmental Management. one copy to the Driller.
and one copy to the, owner,
OW-30 Rmtsed 3/8/90

12/11/2006 17:57 2529953839 KIPNA EET SHORES INC PAGE 11/13
North Carolina
Department of Environment, Health, & Natural Resources
Division of Environmental Management
Groundwater Section
P.O. Box 27687 - Raleigh, N.C. 27611
CONTRACTOR G, ivey �iv,�i�SO I$Di. NO. r�O �J
1. WELL LOCATION: (Show a sketch of the kca#ion on back of form.) -
Nearest ?bum: Anna County
/ � s
4. TOPOGRAPHY draw, slope. hilltop, valley, flat
5. USE oF WELL: l � �!N DATE: AR `Ce
6. TOTAL DLPi DIAMETER; ci
7. CASING REMOVED:
i m
gals. of water I yds. of sand
gels. of water
T i �
Quadrangle No.
WELL DIAGRAM: Draw a detailed sketch of
the wa showing total depth, depth and dia-
meter Q; s=ens reri7aMIng in the weIl, gravel
interval, intervals of ding perforations, and
depths and bTP'es of IM materials used.
Pt?".vQ dR cSG96:2--W-1-3
/K5 W)9 /" 9/ `7
�. 1 • r E?yUqACqNMNT OF MATERIAL,�
•� �A rw• .i- wJ ��
• • hereby 1 abandonnuTl record Is true and am
g� Date 1,2
WELL. LOCATION: Draw a location, sketch on the reverse of this sheet, shov&)g the d1mc-
tion and distance of the well to at least two (2) nearby reference points
such as roads, trAersewons and streams. Identify roads with State High
way road kk nd ication numbers.
Submit orioirial to the Division of Envh-or xntal Marwgment, one copy to the Driller.
and one copy to the ou x-r.
GW--30 Revised 3/8/80

12/11/2006 17:57 2529953839 KINNAKEET SHORES INC PAGE 12/13
North Carolina
Department of Enviro=ent, Health, & Natural Resowt-cs
Division of Environmental Management
Groundwater Section.
P.O. Box 27687 - Raleigh, N.C. 27611
ABANACa1V11lIEMU BEQM
CONTRACTOR � zv�v t c�N EM. NO_4,ga e-
1. WELL LOCATION: (Show a sketch of the location on back of forrn l
Nearest Town: .4_ oelu County LkW_k=_
d, Commun ty, Subdivistorn, Lot No.) guadrangle No_
r
4. TOPOGRAPHY : draw, slope, b ltop. valley, flat
5. USE OF VvT DATE:,y -6go"
►�
B. TOTAL DEPTH: DIAMET,ER:
7. CASING REMOVED:
f diaMeter
8. SEALING MATERIAL:
Neat cea-rrent Sand cement
bags of cement bags of cernent
gals. of water yds. of sand
galq, or water
Type material �i�+/d� 4 121v
Amount. /
WELL DIAQRAM: Draw a detailed sketch of
the wen showing total depth, depth and dta-
mete' of screens rerr inin_g in the well. gravel
interval. intervals of casing perforations, and
depths and types of ail materials used.
pia
1
r�
u • Contractor or • a �50 Date
WELT LOCATION: Draw a location akdcb on the reverse of this street, showing the direc-
tion and durance of the well to at least two (2) nearby reference Points
such as roads. tritersectians and stnoaxn.. Identify roads with State High
way road identifkation n,mnber$_
Submit original to the Division of Erwironmental Management, one copy to the Driller.
and one copy to the owner.
GW-30 rimed 3/8/90

12/11/2006 17:57 2529953839 KINNAKEEf SHORES INC PAGE 13/13
North Carolina
Depar(rn.ent of Mxvirorunent, Heald'4 & Natural Resources
Division of Environmental Management
Groundwater Section
P.O. Box 27687 - Raleigh, N.C. 27611
CONTRACTO1. WELL LOCATION: (Show a sbr-tch or the locaU= on bark of fOrm,)
Nearest Town: County
' A .+ A../ .ice / L • R f
J
4 .S
.►Quadr-angle No.
s
4. TOPOGRAP14Y : draw, slope, hilltop, valley, Dat
5. USE OF WM-L: DATE:
6. TCrr.AL AEPIH;%DIAMEI R
7. CASING REMOVED:
feet diamotez
— It/
S. SFA11NG MATS VLIx L:
Neat .. ce rent
bags of cement bags of cement
gals, of water yds- of sand
gals. of water
Other
Type material , ),mod
Amount ffn Afs .
UVF.L.i. DIAGRAM: Draw a detailed sketch of
the well showing toteed depth, depth and dia-
meter of so =ns renm nIng In the well, gravel
interval, intervals of casing perforations, and
depths and types of U materials used -
AV SCX415�'1-1
(�/ f w' F
9.�]EXPLAIN METHOD EMPLACEMENT OF MA`tERIAL.
T/ ut-W q'
l �
I do hereby ltfy that this well abandonment record is true and exact.
Signature of Contractor or Agent Date 49
WELL LOCA77ON: Draw a location s1mtch an the reverse of this sheet, showing the direc-
tion and cbstanci of the well to at least two (2) nearby reface points
such m roads, intersections and strmnl . Identify roads with State High
way road identii3cation numbers.
Submit original to the Division of Fiwironmental Management, one copy to the Driller,
and one copy to the owner.
GW-30 R¢vfsed 3/8/90