Currituck_Well Abandonment_20240507

WELL ABANDONMENT RECORD For Internal Use ONLY: ,
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JO H N PAUL S I M PS O N 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 I GW-3O is needed. Indicate TOTAL NUMBER of
2930-A wells abandoned: f
,
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 13 (gal.)
J P ENTERPRISE FOR WATER SUPPLY WELLS ONLY:
Company Name 73% HTH
2.Well Construction Permit#:
3RD PERMIT # 410945 7c.Type°fdisinfectamt°Bed`
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.)if known 2.:0 OZ
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 foyt:^,'"'•;?';;. '_'•t P j 7B tonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) "[Residential Water Supply(single) 0 Sand Cement drotbt"' °""i• ', 'El'Dry Clay
❑IndustriallCommercial ❑Residential Water Supply(shared) 0 Concrete Grout MAY `i 2024❑Drill Cuttings
❑Irrigation 0 Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Shy )c .^
t'
u:��•�i 4,r -``' "'�'''� r(explain under 7g)
❑Monitoring ❑Recovery
DFcC 0.3
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 50LB BENTONITE
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑StormwaterDrainage PELLETS
❑Experimental Technology ❑Subsidence Control 11
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer EXCAVATE TO MINUS 3FT,'CHLORINATE WELL,GRAVITY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
POUR 50LB 3/8 BENTONITE PELLETS TO
4.Date well(s)abandoned:4/17/24 TOP OF CASING, HYDRATE TOP,GLUE CAP ON TOP
5a.Well location: AND COVER BACK TO GRADE
DAVID ROGER S
Facility/Owner Name Facility ID#(if applicable) 8. rtificati
eil i105 SOUNDSIDE EST GRANDY NC 27939 4/17/24
Physical Address,City,and Zip S gn lure of Ce ed Well Contractor of ell Owner Date
CURRITUCK 108B00000020000
By fining this form,1 hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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:
36.23266 - N 75.87218 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)(((available.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.Well ID#: abandonment to the following:
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Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth:40 (ft.)
10b.For Iniection Wells: In addition to sending the form to the address in'10a
6c Borehole diameter: 1.25 (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: 5 (t f) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 35 (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
6f.Inner casing/tubing length(if known): (ft) abandoned.
6g.Screen length(if known): 5 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource Revised 2-22-2016