Dare_Well Abandonment_20231204

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
o b v4- A V V ed de-,-W 7a.For Geoprobe/DPT or Closed-lLoop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW 30 is needed. Indicate TOTAL NUMBER of
N wells abandoned:_ �
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Al 1 a-4d,Va rl La!1 e Tn(l, FOR WATER SUPPLY WELLS ONLY:
Company Name iQ (A
. 7c.Type of disinfectant used:
2.Well Construction Permit
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.)ifknown I
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agriculttual ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout i ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) >4Concrete Grout ❑Drill Cuttings
❑hri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Weil: - ❑Bentonite Slurry ❑Other(explain under 7g)
Monitoring _ ❑Recovery
'Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Jao I ba
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage s
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of t he,abandonment procedure:
❑Geothermal(Closed hoop) ❑Tracer f�,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 8Q'e a 11 a o.hed
4.Date well(s)abandoned: I U It, I A 3 I 1 r 2023�
5a.Well location
mare C��, � .. "_, -•-,r �-7 l,�.0
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
qba AIlarshail �. #Allns Dr, Man4eo. Ill O 11 ao a3
Physical
Address,City,and Zip Signature of Certified Well Contra or or Well Owner Date
2)A-1'e• By signing this form, I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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 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 record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same comstructionlabandonment you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
l Division of Water Resources,Information Processing Unit,
6b.Total well depth: L- (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I
/_11 tt 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: lY '8 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: I
3I `4 I Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: p^ (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 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
6E Inner casing/tubing length(if known): tJ A (ft.) abandoned.
6g.Screen length(if known): N 1 A (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

November 20,2023
RE:Well Abandonments
a
962 Marshall Collins Dr
Manteo, NC
7g. Provide a brief description of the abandonment procedure: I
Dug out approximately 3' in diameter by approximately 2'-2.5'in depth in order to gain access to,cut
2" PVC below hardened.existing concrete.grout.-Once-cut.manually removed stubbed up section of 2"
casing contained in metal security pylon with concrete grout-plug and removed from site.
Remaining 2" PVC casing was then extended to grade and casing and screen filled with concrete to the
top then compacted and watered in..Original hole dug out was filled with exisi ing material with
approximately a 2' radius remaining by approximately 1' deep then filled with concrete,watered in and
then relandscaped over. j
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