Currituck_Well Abandonment_20231228 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1..Michael
Contractor Information: WELL ABANDONMENT DETAILS
M Young 1 ou ng 7a.For Geoprobe/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 1 GW-30 is needed. Indicate TOTAL NUMBER of
2370A wells abandoned: 4
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,eta)iflmown
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 s Neat Cement tit _ pq.,�s .,,,❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement GroutL" r-+► V�Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout DEC `q 8 2023 ❑Drill Cuttings
❑Ini ation ❑ Specialty Grout U ❑Gravel
Non-Water Supply Well: ❑Bentonite S(t r �tg{1?fm ther(explain under 7g)
RMonitoring ❑Recovery r'(;y;9j
Injection Well: 711 For each material selected above,provide amount 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: 11-27-2023 of the well to the surface, removed tremie pipe
5a.Well location: topped off grout, removed well cover, cement patch
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Facility/Owner Name Facility ID#(if applicable) S.CerM4��
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850 Puddin Ridge Rd. Moyock, NC. /': 12-13-02023
Physical Address,City,and Zip Signature o Certified Well Contractor no wner Date
Currituck By signing this form, I here ce that the well(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC .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:
36.461797 N -76.202597 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
ONLYwith the same construction/abandonment,you can submit one form.
� 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M V A�V—3 abandonment to the following:
Division of Water Resotrces,Information Processing Unit,
6b.Total well depth: 10 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter 8 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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6d.Water level below ground surface: (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft,) 10c.For Water Suonly&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
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
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