Currituck_Well Abandonment_20231228 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Young 7a.For Geoprobe/DPT or Closed-L I op 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
2370A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Fishburne Drilling Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if/mown
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 a Neat Cement Grout_ ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement fit Clay
❑Industrial/Commeroial ❑Residential Water Supply(shared) ❑ Concrete Grout G ll Cuttings
❑lni ation ❑ Specialty Grout DE(; 2 8 2023 ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery VieO Pr ,
Injection Well: 7f.For each material s�l'esY'�dj o�vrmount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation water 37 gallons Bentonite 20 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage cement 47 pounds
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed grout, lowered tremie pipe to the bottom
of the well, pumped grout thru trremie plupe to the bottom
a.Date well(s)abandoned: 1 1-27-2023 of the well to the surface, removed tremie pipe
5a.Well location: topped off grout, removed'well cover, cement patch
Academi
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
850 Puddin Ridge Rd. Moyock, NC. 12-13-02023
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Physical Address,City,and Zip Si re o ertified a ontmctor or Wel er Date
Currltuck By signing this form,I hereby cerli lh t the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 0217.01 r 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.461907 N —76.202758 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-watersupply wells
ONLY with the same constructionlabandonment,you can submit oneform.
10a. For All Wells: Submit this"form within 30 days of completion of well
6a.Well ID#:
M W-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 10 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 0-) 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 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service tenter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 00 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): 2.5 (ft) abandoned.
6g.Screen length(If known): 7.5 (ft-)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016