Currituck_Well Abandonment_20231006

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAAILS
` ~•'I I 1 tln1J fltiy J A J l i 511 7a.For Geoprube/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 G'N-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):Y (gal.)
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Caro0. ,, V Ice < p4 ( K$�ruc f l0 h 1✓�L FOR WATER SUPPLY WELLS ONLY:
1
Company Name i�t 7c.Type of disinfectant used:
2.Well Construction Permit#: 410 lC}3 vsr W P 1 ` 014
List all applicable well construction permits(i.e.VIC.County.State.Variance.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 0 Neat Cement Grout IBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) • 0 Sand Cement otit�,,„k" F.:is r f ti�.❑'tr ,�D.i}Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Groin�'• �"�'��""'' 0.0"DellCuttings
❑lrrigation 0 Specialty Grout 0 C T 0 u 20230 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery IFSwr,61.<a�i3 P r',f* de amount of materials used:
Injection Well: 7f.For each material seleete • l o-feerov
❑Aquifer Recharge ❑Groundwater Remediation 7/I .fK(
❑Aquifer Storage and Recovery ❑Salinity Barrier r '
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 1
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer t�
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) ut. t? !crop occt rilra welt
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4.Date well(s)abandoned:
I Sa.Well location:
Robert- CatoLtwe'l
Facility/Owner Name Facility IDe(if applicable) S.Certification:
o o(o3 Sa pi fir R4 i CO roller , 07TV ago 023
Physical Address.City.and Zip Signature f Certi ed Wel ontractor or Well Owner Date
/' rl fuck 087/'66o0(c10009
�t� By signing this form.1 hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) ' accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record hass been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lat/leng is sufficient) f q 9.Site diagram or additional well details:
36 3o '-I N 7 5 51 -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 record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.WellID#: 6G7 6 on purop inside abandonment to the following: '
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
4 WO j, 10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in 1 C�`(J( B above, also submit one copy of this form within 30,days of completion of well
-�( abandonment to the following:
`e W�� Division of Water Resources,
Underground Injection Control Program,
6d.Water level below ground surface: (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
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lOc.For Water Supply&Infection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft)
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): (ft.) abandoned.
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6g.Screen length(if known): (ft.)
Form GW-30 • North'Carolina Department of Environmental Quality-Division of Water Resources ,q , Revised 2-22-2016