Pasquotank_Well Abandonment_20221222

WELL ABANDONMENT RECORD Ralraerral Use ONLY:
1.Wen Contractor info Lion: WELL ABANDONMENT DETAILS
JOHN PAUL SIMPSON 7a.For Geopmbe/DPT or Closed-Loop Geothermal Wefts having the same
Wo11 Contactor Name(or we0 owmr personally abao" R m hauber pope Z�. well eonstructiun/depth,only I G W-30 is needed. Itdieme TOTAL NUMBER of
2930—A i 7 wells abandoned:
ED
NC Well Contactor Certification Number 7b.Approximate volume of water remaining in wd(s):0 (gal.)
J P ENTERPRISE '1`� 2 2022 FOR WATER SUPPLY WELLS ONLY:
Compwry Name in;c;rr t:ic� err;3saurV�Una 73% HTH
7r.Type ofdafnfbw ee need•
iEF:ll3r asCIDEM 38678.kW90aiWW 3165
2.Well Contraction Permit R:
lid ull upp1ft b1e,,v11 cwvnaretw perwi#he UM.C.My..Soak Pr6ane.e )iftxrwn ,5 OZ
71 Anr.m of disinfectant ored:
3.Well case(cheek wall am):
Water Supply Well: 7e.Sealing materials used(check all that apply):
DAgricdtual l3MmucipaiTubtie D Neat Cement Grout a Bemonpe Chips or Pellets
OGcothermal(Heating/Cooking Supply) DResidemial Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
Dlndustriat/Commercial DResidential Water Supply(shared) ❑Concrete Grout ❑Drift Cuttings
Dirrigation ❑Specialty Gmnt D Gavel
Noo-Water Supply Well: ❑Baca ritc Slurry ❑Other(explain undo 7g)
!!Monitoring ORsxxwcry
Injection Well: 7E For each nnterial selected above,provide amount of materials used:
-7AmtiferR=narge Dcr«ndwa,e Rem«ha an 40 LB BENTONITE
7].Aquifa Stoagc and Recovery DSalmity Bari.-r
DAquifer Test Dsuarms ter Drainage
DExperimenal Technology ❑Subsidence Control
7g.Provide a brief description of The abandwment procedure:
°Geothermal(Closed Loop) UTrater REMOVE WELL HEAD VAULT, PULL OUT AND
DGeothemul Head Cod" Return DOMer leaphout insider 7gi
REMOVE ALL 2" PVC CASING AND SCREEN
s.Date weu(x)abandoned: 12/13/2022 CHLORINATE BORE HOLE, GRAVITY POUR
So.Well location: 3/8 BENTONITE PELLETS INTO BORE TO GRADE
VANGUARD PROPERTY GROUP STARBUCKS E.CITY
Facility/(]wear Namc Facility ilfp(ifopplinble) &CertiButlow
1313 W EHRINGHAUS ST ELIZABETH CITY NC 27909 12/13/2022
Physical Addeo;City,and Zip fcrhiried well ronlosor err WNI Oawer Date
PASQUOTANK ffff:UST PMDEW a3961
Bw signing thir form, 1 hereby mrife*hat the rwellia)won(were)abandoned in
County Parcel ldrraificotion No.(PIN) aYy>n uce with ISA A(CAC 02C.0100 or 2C.0200 Well Corabuction Standards
and that a cop),of this record has been provided to the well owner.
5b.Latitude and longitude in degeets/minutes/secoods or decian d degrees.
(ifwe0 field,oue iat9ong is s.ffi(eat) 9.Site diagram or additional well details:
36 17 40 N 76 14 24 W You may use the back of this page to provide additional well site details or well
abandonment dcails. You tray also attach additional pages if ncccssary.
CONSTRUCTION DETA"OF WELL(S)WING ABANDONED SUBMITTAL INSTRUCTIONS
Altachwvilmmimclimremrd(s)il'awilahle. Formulupleinlrrvionarron-%Wt supptya,ls
ONLY,wrh/he same mnrrrwninmbhandnnrnrn4 mu con rvhmir rxde jrwa.
IOa. Fer All Wells: Submit this form within 30 days of completion of wall
6a.Wall, ,,, MW #6A abandonment to the following:
Division of Water Resources,Information Processing Unit
6b.Total weft depth: 12 (ft.) 1617 Mail Service Center,Raleigh,NC 276W1617
lob.For luieclton Wells: In addition to sending the form to the address in lost
6c.Borehole diameter. 2 tin.) alsm e, also submit one copy of this form within 30 days of completion of well
abandonment to the toliowing:
6d.Water level below ground surface: 6 (ft.) Division of Water Resources,Underground Injection Control Program,
t636 Mall Service Center,Raleigh,NC 27699-1636
fie.(Alter casing length(d known): 1.5 (ft) lot.For Water Sutmly&Injection Welk: 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): (fL) abandoned.
6g.Screen length(if known): 10 IDJ

WELL ABANDONMNT RECORD For larmmi Use ONLY:
1.Well Contractor Informativa: WELL ABANDONMENT DETAILS
JOHN PAUL SIMPSON 7a.For Geoprobe DPT or Closed-Loop Geothermal Wells hating the same
Wall Coarrxtor Nametorwellowoert'. ally.I%udmingwellonhiwberprocny) well construction/depth,only l GW-30 is needed. Indicate TOTAL NUMBER of
:
2930—A wells abandoned
r-.z L, ,�i
NC Well Contractor Certification Number P r Approximate volume of water remaining in well(s): O (gal.)
J P ENTERPRISE nLr 2 2 2022 FORWATERSUPMYWELIS ONLY:
f�"ywi y 73% HTH
IMF:USTa«mENr hesis:deati lldA :
U Type of distnrecmnt Kara:
2.Well Comtroction Ferniest: ra. c ll�h^, �
LW a1I u,,l4'.b1e well[WtraM'1 ♦OHMS A.UM.47~ Shalix Farwrme,ek.)i/bwwr disinfectant OZ
7d.Amount of disiafeaat uard.•
3.Wen aw(Cheek wen we):
Water Supply Well: 7e.Sealing materials used(cheek of t►it apply):
DAgricultural C Neat Cement Groot N Hentonite Chips or Pellets
OCreothemW(Heating/Cooling Supply) oResidenual Water supply(single) L Sand cement Groot ❑ Dry Clay.
❑Industrial,Commercial UResidential Winer Supply(shared) ❑ Concrete Crt t ❑Drill Cuttings
Dirrigation ❑Specially Grcui ❑Gavel
:Van-Water Supply Well: ❑Bemo mic Slurry ❑Other(explain under 7g)
♦!Monitoring ORcnwery
Injection Well: 7E For each material selected above,proem amount of materials used:
❑.Aquifer Recharge nGmnchmicr Rcmediation 30 LB BENTONITE
7Aquifcr Storage and Rarosvy Dsalonity Barrier
::]Aquifer Test 17Stwmwater Drainage
❑Experimental Technology OSubstlevice Ctn trot
OGeothermal 7g � tku
' akrief aiptian of the abandonment procedure:
(Closed loop) OTmnr
Heating/Coo' Return 00dwir(explionturder7 REMOVE WELL HEAD VAULT, PULL OUT AND
REMOVE ALL 2" PVC CASING AND SCREEN
.Date weu(a)x1madoned: 12/13/2022 CHLORINATE BORE HOLE, GRAVITY POUR
5a.Well location: 318 BENTONITE PELLETS INTO BORE TO GRADE
VANGUARD PROPERTY GROUP STARBUCKS E.CITY
Facilinva)wrier Name Facility TDs(ifspplkable) LCertlRcoDa :
1313 W EHRINGHAUS ST ELIZABETH CITY NC 27909 12/13/2022
Physical Addtear,City,and zq "r Trial wax o sent w wall Oaaw One
PASQUOTANK FEPUSrmCWEW#3667
Br signing rhfr form, I hereby,rvrti(i'that fhe wirli t) "nr(were,)abandoned in
County Parcel idnnlfieuim No.(PIN) accordance Kith 15A NCAC OIC.0 HM or IC.0200 Well Cimurmcpon Standards
and olW a copy of this mood has been provided to the well owner.
Sb.Latitude and kmgitude in degredminNe/arcaods or decimal degree:
(if well fwK me tat ioug is suRcienq 9.Site diagram or additional well details:
36 17 40 N 76 14 25 W You may use the back of this page to provide additional well site details or well
abandonmcntdemils. You may also attach additional pages ifneccucuy.
CONSTRUCTION DETAILS OF WELLIS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
.4U.b wellcoraoachm ocard(s)i/aval.W. Far 01al*kiSW6oaoraon-wnlers W1v wells
ONLY.urb the.mme maurvnim✓ohandanmrm mu can whourearjurw. Ifla For All Wells: Submit this form within 30 days of completion of well
6a.Well Ion, MW#16 abandonment to the following:
Division of Water Resources.Information Processing Unit.
6b.Total well depth: 12 (ft.) 1617 Man Service Center,Raleigh,NC 276W1617
10b.For taiection Wens: In addition to sending the fmm to the address in 10a
6e.Borehole diameter: 2 (io.) above, also submit one copy of this fart within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 6 oft) Division of Water Resources.Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-106
6e.Outer easing length(H krwa): 1.5 (IL) 10c.For Water Supply&Infection Welk: In addition to sending the form to the
addnecs(cs):dote,also submit one copy of this form within 30 days of coogdetion
of well abandonment to the county health department of The county where
of.Inner easing/tubing length(N known): oft,) abandoned.
6%.Screen length(if known): 10 oft.)

WELL ABANDONMENT RECORD For Ira 1Use ONLY:
1.Well Contraclor ImAnnead": WELL ABANDONMENT DETAILS
JOH N PAU L SI MPSON 7a.For Geoprobe/DPT or Chased Loop Geothermal Wens haling the same
Well Common,Naas,W we0 owner pvwnally abandoning well on hialMr Festivity) well construction/depth,only l G W-30 is needed. Indicate TOTAL NUMBER of
-- >N s• B wells abandoned:
2930-A F%7.6, ,E-; s i rI
NC Well Contractor Certification Nun ix, 7b.Approalrnsle volume of water remaining in wdl(s): O (galJ
J P ENTERPRISE Dc- 2 2 2022 FORW'ATERSUPPLYWFII¢ONLY:
Company Name 73% HTH
Ill(Js*T"a"wI..�a...u�aata��'.g�"a'�,''`�('r�'i 7e.Type of Jivntacmnt uae�
2.Well Construction Pern it%:�:UST 114COMW 3t6.yr�was...�.rRY 3106
Lest ar"Pik bir ner conarrwoon omobr r.e LW..caw.smtr.Po,a.re.�)ifk..,.,1 .5 OZ
7d.,lrmunl of disinfectant used:
3.Well use(check wee(se):
Water Supply Wen: 7e.Sealing mnterisls used(check a8 that apply):
[]Agricultural 13mmucip"Ibitc C Near Cement Cumn s Beattedo,Chips or Pellets
06cothemull(He iting/Cooling Supply) oRes;armial Water Supply(single) ❑Sand Cemrnl Gnml ❑Dry Clay
❑Ndustrial/Comarercial 111tesidential Water Supply(shared) ❑Concrete Limn ❑Drill Carriag;
01ni rion ❑Specialty Gmut O Gravel
Nee-Water Supply Wet: ❑Boaoaitc Slurry ❑Other(explain and T 7g)
IlMonnoring ORccovesy
Injection Well: 711.For itch material selected above,Provide sasouet of materials used:
❑Aquifer Recharge []Groundwater Premeditation 30 LB BENTONITE
[]Aquila Storage and Rccm'ay []Sa iney Bsri t-
❑Aquifer Test CISto mwasa Dramage
OEuperim®sl Technology CSuhtadem:e Control
OCxothemul ICbud Loop) CTuasa 7S wide a brief description of the ahnn/sument petWve:
OCacothermal(Hearin Coon Return pgha under 7 REMOVE WELL HEAD VAULT,PULL OUT AND
REMOVE ALL 20 PVC CASING AND SCREEN
6.Date well(a)ahaedoued: 12/13/2022 CHLORINATE BORE HOLE, GRAVITY POUR
Sec.Well location: 318 BENTONITE PELLETS INTO BORE TO GRADE
VANGUARD PROPERTY GROUP STARBUCKS E.CITY
Facility/(Tuner Name Facility ID#(ifapplieabk) LCerdReaft�-
1313 W EHRINGHAUS ST ELIZABETH CRY NC 27909 %V12/13/2022
Physical Address,City,and Zip Staunton, rcwhfiod Well clilt or wall Owner Dee
PASQUOTANK REP UST FOADENT a 307
Br signing this bone. I hereby(xrtifi'that the arf/(r) nisi (were)ahandrmed in
County Puce!IdewficaNm No.(PFN) acnadmtce wvth 15A NCAC 02C.0100 or 2C.0200 Well Courtruttion Standards
Sb.Latitude and longitude in degrees/mioutes(secoods or deeiasl degrees: atd Bata eons of this re vd has been provided to the well owner.
(ifwe0 beta,one lot long is sutTiccem) 9.Site diagram or additional well details:
36 17 40 N 76 14 23 W You may use the back of this page to pros'ide additional well site details or well
abandonment details. You may also attach additional paga if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSFRUCITONS
Arlo h6 llCO imcliallrecord(J)I,faWilabla Form 1.),Ieilyecfimw n-unlersupplynelb
ONLY nuh the amue a»narusvilar/aMndnnmenr mu can rviuwr one farnl.
�,s
- - IOa. For All W'elis: Submit this form within 30 days of completion of will
6a.Well�. MW #4 abandonment to the following:
Division of Water Resources,Information Processing Unit.
6b.Toll well depth: 12 (ft.) 1617 Man Service Center,Raleigh,NC 27699-1617
Milt.For luiertfon Wells: In addition to sending the faun to the address in 10a
6c.Borehole disuusti r: 2 (in) 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: 6 (ft.) Division of Water Resources.Underground Injection Control Program,
1636 Man Service Center.Raleigh,NC 27699-1636
be.Outer casing length(ff known): 1.5 (R) 10c.For Water Saooly&loiection Welk: In addition to sending the farm to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health depanmrnt of the county where
of.Inner casing/tubing length(if known): (ft) abandoned.
6g.Screen length(if known): 10 (ft.)

WELL ABANDONMENT RECORD Fe,lmaml Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JOH N PAU L S I M PSON 7a.For GeoprobdDPT or Closed-Loop Geothermal Wells hating the same
Well Corrector Name,(w weh owacr personally abandoning well on hWher pmlcmy) well constructimudepth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2930-A wells abandoned:
fir^, E,VED o
NC Well Contractor Certification Number `{ 7A Approximate volume of water remaining in well(s): (gall
J P ENTERPRISE ncr 2 2 2022 FOR WATER SUPPLY WELLS ONLY:
Company Name J
5 T�T�paam:.ree�.ceed73/ HTH
2 Well Construction Ps. a:FEW:lmr� 314
List al/irp4wb4 ndt coo haeriiw/wwAr ftc UIC.Cvurn.Seat Pwhaac es:)fjbsrnm .5 OZ
Ti Anra1 MSsinteetant uat�
3.Well use(cheek well use)-
Water Supply Well: 7c.SeaYg urterials used(cheek all that apply):
❑Agricultural QMuoievaFPabtic G Neat Ccuaut Grout s Benumite Chips or Pellets
DGeothermal(timung/Coding Supply) []Residential Water Supply(siogle) El Saud Cement Grout ❑Dry Cis)'
❑Industrial/Commercial OResidemial Water Supply(shared) ❑Concrete tmwt ❑Drill Cuttings
71tri [ion ❑Spccialty Grout ❑Gmtel
Noo-Wmter Supply Well: ❑ Baaonitc Slurry ❑Other(explain under 7g)
IlMonitming DRcwvcry
Injection Well: 7L For curb auterial selected abwcS provide amount of materials used:
❑Aqud'er Recharge, oQuundwater Resnothuia, 30 LB BENTONITE
MAquihx Storage and Rtabsvy, []Salinity Barrio
O.Agwfer Test []Sturmssmer Drainage
❑Experimental Technology []Subsiderce Control
OCxo[hemtal lCkned Loop) []Tracer �'�"'�a Miefdosriptlaa K the abandonment procedure:
RE VE WELL HEAD VAULT, PULL OUT AND
IlGeothermal(Hearin Cool Return g[] her( himutder7
REMOVE ALL 2" PVC CASING AND SCREEN
4.Date weigs)abauduned: 12/13/2022 CHLORINATE BORE HOLE, GRAVITY POUR
5a.Well location: 3/8 BENTONITE PELLETS INTO BORE TO GRADE
VANGUARD PROPERTY GROUP STARBUCKS E.CITY
F.0ho Nlweer Nsmo Facility ID#(if apliabk) Lfadlratim:
1313 W EHRINGHAUS ST ELIZABETH CITY NC 27909 %�_
F q 12/13/2022
Physical Addrr;City,and Zip slowar, Fcr..fiw well Core c or ex wells I Psove Due
PASQUOTANK REF:UST PMADENT0 3067
ly signing thlr(mmr, I hereby-rertffi'that the xrf//.rJ war(were)ahondrnred in
County Parcel hinnifration No.(PIN) arco dance Kith 15A NGIC 02C.0l00 or 2C.0200 Well Construction Standards
and that a<qie of this rerx d Aar,been provided to the Kr//owner,
Sh.I.alitatk and longitude in degreeslrrdoutWsernreds or decimal degrees:
(ifwe0 fold.one honing is sufficient) 9.Site diagram or additional well details:
36 17 40 N 76 14 24 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 DCE FAII C OF WELLAS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Auoehmilronslrunionree dts,ilavwlahle. For multiple o ectiw ornom-wereupph mils
ONLYwi,h IAe........t,iici. IYI/IA/InMM(.1'n [on i.h.,MM/o,o,
- - 10a. For All Wells: Submit this farm within 30 days of completion of well
6a.Well IDp: M V Y1t' #8 abandonment to the following:
Division of Water Resources,Information Processing Unit.
6b.Total well depth: 12 YQ 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For lnieclJou Wells: In addition to sending the form m the address in 10a
6c.Borehole diameter: 2 (Ls.) above, also submit ewe copy of this feast within 30 days of completion of well
abandonment to the following:
6d.W aler level belo,ground surface: 6 (ft.) Division of Water Resources.Underground Injection Control Program,
16.36 Hail Service Center,Raleigh,NC 27699-1636
fie.Outer casing length(R dwra)r 1-5 (R.) 10c For Water Supply&iobtelien Wells: In addition to sending the form to the
addrecs(cs)above,also submit one copy of this form within 30 days of com pletim
of well abvdooment to the county health department of the county where
6f.Inner casing/tubing length(H known): (ft.) abandoned.
6g.Screen length(if known): 10 00

WELL ABANDONMENTRECO" For hacmal Uu ONLY:
I.W'ell Contractor Information: WELL ABANDONMENT DETAILS
JOH N PAU L S I M PSON 7a.For Geopmbe/DPT or Closed-loop Geothermal Wells hsvtg the same
W<OCoouactor Name(orwcBowoerpers. Ky abandoning well on umber propcny) well construction/dcpth,only l GW-30 is needed. Indicate TOTAL NUMBER of
2930-A wells abandoned:
NC well Contractor Certification Nr red,,, Q^a �� i )^APprosimafe volume of water remaining in well(s):0 (gal.)
J P ENTERPRISE 4 !! Li FOR WATER SUPPLY WELLS ONLY:
Name nc r LUZZ Company —" 7e Ty
pe of disinfectant omdk
2.Well Conlncdma Per�t7f:liFF:test NI8lE PAKW 3196 Isr33M.Fot0.ER 1. Z
List Wl applauble nvll cuwnwfixeperwua oc l/IC.C :Jv 7d.AmoaW O(IGsidtehat used: •5OZ
3.Well ore(rheelt well we):
Water supply Well: 7e.Sealing materials used(check all that apple):
DAgriculmml 0MunicipabPab6c ❑Neat Cement Grout a Betdonite Chips or Pellets
oGeoUxrmal(Heatingjcooling Supply) f]Rsidential Water Supply(single) ❑Sand Cement Cann ❑ Dry clay.
❑Industrial/Commercial OResidential Walls Suppy(shared) ❑Concrete Cmur ❑ Drill Cuttings
Obligation ❑Specialty Grout ❑Gacel
Noe-Water Supply Well: ❑Baoondc Slurry ❑(Sher(explain udcr 7g)
!lbionitoring ORcwvcry
Injection Weil: 7L Far each mate"mtgretM above,provide amount of tr aterials used:
ClAcluifer Recharge QGamdwwter Remedi am. 35 LB BENTONITE
❑Aquifer Slomge and Rocasxy nsal pity Ba cr
O.Aquifer Test OStorm»ater Drainage
OExperimental Technology QG '+Com<d
7g.Provide a brief dtoa}Dma of the abandonment procedure:
OGeothermal(Closed Loop) OTrater
ocmthemlal(Heati Rd= OOther under REMOVE WELL HEAD VAULT, PULL OUT AND
�f
REMOVE ALL 2" PVC CASING AND SCREEN
4.Date welks)abandoned: 12/13/2022 CHLORINATE BORE HOLE, GRAVITY POUR
5a.Well location: 3/8 BENTONITE PELLETS INTO BORE TO GRADE
VANGUARD PROPERTY GROUP STARBUCKS E.CITY
Faelity/Owner Node FacilitylDotifappli�t) LCarliiemOae
1313 W EHRINGHAUS ST ELIZABETH CITY NC 27909 12/13/2022
physical Address,City,and Zip err tifoed wen m seer.w well owrar D,m
PASQUOTANK REF UST VICK)EEPIra3057
By signing Ihi�jnrnl. 1 herAry mrYlfr IMI the well(s)suns(»ere ahandnned in
C.1y Parcel Idem4s;on No.(PIN) accontlance with 15A NCAC 0 C.0100 or 2C.0200 Well Consmlcrlon standards
5b.Latitude mad s utes/sesmads or decimal and drm a copy of this tecnrd has been providedW the well owner.
��� � deRrega:
(ifwe0 field one ladlung is sufiiciect) 9.Site diagram or additional well details:
36 17 40 N 76 14 25 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 nacssary.
CONSTRUCTION DETAILS OF WELL(S)SUNG ABAINDONED SUBMITTAL INSTRUCTIONS
AlmrhwellcaimciioarecardhJilacailahlc FwnudjVleiyeetianwnoa-. soppkw ffi
ONLY 4A the..raaorwxion.ohonAanmrm.rya run rxhmir cure l,w_ 10a. For AD Wells: Submit this form within 30 days of completion of well
6a.Well IDN: MW #12 abandonment to the following:
Division of Water Reroarces,information Processing Unit
6h.Total well depth: 12 (ft.) 1617 Mail Service Center,Raleigh,NC 2 7 69 9-161 7
10b.For oiectfoo Wells: In addition to sending the fmm to the address in l0a
6c.Borehole diameter: 2 (i.) abm e, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.l3'ater level helow ground surface: 6 (ry) Division of Water Resources.Underground Injection Control Program,
1636 Mail Service Center.Raleigh,NC 27699-I6M
6e.Outer casing length(if dens): 1.5 (tL) /fie-Far Water Sunaly&Inkittioo Webs: In addition to sending the farm to the
addiessls)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
of.Inner casing/tubing length(if known): (ry,) abandoned.
6g.Screen length(if known): 10 (ry.)

WELL ABANDONMENT RECORD Far lateral the ONLY:
1.Well Comtraclor Information: WELL ABANDONMENT DETAILS
JOHN PAUL SIMPSON 7k For Geoprobe/DPT or Cloud-Loop Geothermal Web hating the same
Wa Contractorthuc(orwileweerlx'. I[yaba,doning,yicl well construction/depth,only l GW-30 is needed. Indicate TOTAL NUMBER of
2930—A - t 11 wweils abandoned:
NC Well Conlractw Certification Number nUr q 2 7b.Approximate volume of water remaining in well(s): 0 (gal.)
J P ENTERPRISE L FOR WATER SUPPLY WELLS ONLY:
Naar imp-,; "� 73% HTH
Compatry r-.� :"3xa 7e Tv prafd'ainfeedntused:
IEF:UST atCIDEE1R PAN 3165
2.Well Construction Per=h N:
Use Wl uppJhvblr oral/cmaawfiwPe kc.UIt:Canon.Sate Ferhaar.ek.1 iftrn.rn , .5 OZ
7d.Aaasuat tsfdiriaketant used.
3.Well au(cheek well ate):
Water Supply Well: 7e.Sculling materials used(check all that appl)):
❑Agicultural CMuaicipa6Pubbc C New Cement Grout a Bentooite Chips or Pellets
OGeothemed(Heating/Cooling Supply) ❑Residential Water Supply(single) C Sand Cement Gomm ❑Dry Clay.
Llndushial/Commercial CResidential Water Supply(shared) LConerele Gout ❑Drill Cuttings
❑hri lion I- Specialty Grout ❑Gravel
Nan-Woter Supply Well: C Buvemnh Slum ❑Other(explain under 7g)
SMonitoring 01tctvrcry
Injection Well: 7L For each material selected above,provide anaunt of materials used:
DAquifer Recharge OGrowxvae Itcroodumon 25 LB BENTONITE
113Aquifa Storage and Recovery 0Saliuty,Barite
❑Acituier Test ustamsvaer Drainage
OExperimemal Technology 0Subsidence Control 7g.Provide a brief elesaipir of the aboodaaaeat procedure:
OGeota:rmal(Closed Loop) oTracer REMOVE WELL HEAD VAULT,PULL OUT AND
OGeothermal Drati C Return) ❑Other) loinutdc7
REMOVE ALL 2w PVC CASING AND SCREEN
a.Dote wellis)abandoned: 12/13/2022 CHLORINATE BORE HOLE, GRAVITY POUR
So.Well location: 3/8 BENTONITE PELLETS INTO BORE TO GRADE
VANGUARD PROPERTY GROUP STARBUCKS E.CITY
I'ved Atworr Name Facility IDa lifapplic#) bCerNONaC
1313 W EHRINGHAUS ST ELIZABETH CITY NC 27909 %V12/13/2022
lil
Physical Adilmn,City,and zip of ified well core w Well Ora Date
PASQUOTANK rEF:UST 1Ra Et/Taffi
By signing dd form, I hare7ry'rertffi-that the neB(s)rue/rein)ahandrmed in
Conmy Pared Tdc ifirt'ton No.(KN) acconlaure Kith 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of"renrd Gas been provided to the well corner.
WLatitude and longitude in degrees/suiaates/sceonds ordecind tkgreea:
(ifwell lidd nnc Ins long i,,ulticicnu 9.Site diagram or additional well details:
36 17 40 , 76 14 24 W You may use the back of this page m pmvide additional wall site details or well
abandonment details. You may also attach additional pages ifneccuatry.
CONSTRUCTION DETAILS OF VIEWS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Aaacb wellcomrrurt/ar r¢rnN/s)iJawilablr. Farnadap/e iniertiw arson-onto rupph,w.11s
OA'2Y,vuh rhe.mntr rnagnaib ahardn-we.t mu rnn nhrwr mw Frew- IOa. For All Well Submit this form within 30 days of eormpktitm of well
on.Well IDf: M W #19 abandonment to the following:
Division of Water Resources,Information Processing Unit
6b.Total well depth: 12 (it.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 106
6c.Borehole dhsnndw.. 2 pa,) abate, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 6 ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer easing length()f known: 1.5 (fL) 10c.For Water Supply&Injection WNLs: In addition to sending the foam to the
addms(esl above,aLso submit one copy of this foam within 30 days of completion
of well abandonment to the county health department of the county where
of.Inner easing/tubing length(ifknown): (B,) abandoned.
6g.Screen length(it'known): 10 (fL)

WELL.ABANDONMENT RECORD For Interval Use ONLY:
I.Wen Coatracmr Information: WELL ABANDONMENT DETAILS
JOHN PAUL SIMPSON 7a.For Geoprobe/DPTorCbud-Laop Geothermal Wells haing the same
Will Coancw Narme(a wc0 awocr pro. Ily abandoning well on hWhcr property) well construction/depth,only l GW-30 is needed. Indicate TOTAL NUMBER of
2930-A _• -rp.^• + 7,_,..\j,t � wells abandomed:
}
NC Well Contractor Certification Number y�'`�-t.•r 7b.Approximate volume of water remaining In well(s): O
J P ENTERPRISE ,Z 9 nzz FOR WATER SUPPLY WELTS ONLY:
Company Name 73%D HTH
r„ r7 1jnA 7e Type aftWfufac7>nR afed:
2.Well Coostruetloa Pernik d:REF LISTryn•, Fµ 3te6
firs ulf alplk-abfe.,rl!nwradvar yv�ie fee 1//C.CcaN_ Sit Viiarr.eh.l iJteur -5 OZ
7t AraW of utad:
3.Wall mar(chart well ter
Water Supply Well: 7e.Sealing materials need(cheek a•that apply):
DAgieultural QMwieipaL'Wblie C Near Cement Craut N Bentonite Chips or Pellets
DGeothermal(Heating/Cooling Supply) ❑Residential Water Sappy(single) D Sand Cement Grow ❑Dry Ctay
Olndustrial/Commercial ❑Residential Water Supply(shared) D Concrete Grout D Drill Cuttings
Ofi-rigation ❑Specialty Cmmt ❑Gravel
No -Water Supply Well: ❑ P"wr itc Slurry ❑Orba(explain under 7g)
eMomh ring ORawcry
Injection Well: 7E For each material.elected alum c,provide amount of materials used:
OAttuifer Recharge OCaam,ammer Remciirmn 30 LB BENTONITE
DAquifcr Smmg:and Rcwstny OSalinity Baricor
DAquifu Test DStormsvater Dvamage
DExperinemal Technology DSuhside contml
7g.Roc ide a kiddeteriptiaa of the abaodoument procedure:
DGeotherrnal(Closed Lapp) OTraca
[3Geothmnal(Headn C Return) OOther lamsmder7 ) REMOVE WELL HEAD VAULT, PULL OUT AND
r�
REMOVE ALL 2" PVC CASING AND SCREEN
4.Date well(s)abandoned: 12/13/2022 CHLORINATE BORE HOLE, GRAVITY POUR
Sa.Well location: 3/8 BENTONITE PELLETS INTO BORE TO GRADE
VANGUARD PROPERTY GROUP STARBUCKS E.CITY
Fxilm:Ltwrcr No. Facility IDs(ifgpliable) ref
1313 W EHRINGHAUS ST ELIZABETH CITY NC 27909 \ IL 12/13/2022
Physical Addae,City,and 7-a a ieemfi wen con tar Zr w Owmr wee
PASQUOTANK REF:UST a,ICIDEW a 3557
By.s ing thin(arm,1 herehy earl fr that the wr0(s)war(were)ahandmird in
County Parcel Identification No.MK) amatdana e wtth 15A NCAC 02C.0100 or 247.0200 Well Construction Standards
road thal a,apt o(Ihis record has been provided 0 the well owner
50.Latitude and longitude in deprees/miautedeetatlswderiral degrees:
(ifwe6 field one bClone,,suticicn 1 9.Site diagram or additional well deals:
36 17 40 N 76 14 23 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 ifnocessary.
CONSTRUCTION DETAILS OF WELLfS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
.eturh wet/ronstrr¢tian rerordfi)il ova/ah/e. Forn,u(uple injec(ionairon-narer.ru/plyxvdls
OA'LY nirb rhe.ume ennnrvcrion alwndnnmenr,mu can suhmir ore f rn,.
10%. For All Wells: Submit this form within 30 days of completion of will
6a.Well con, M W #9 abandonment to the following:
Division of Water Resources,Infermetloa Processing Unit,
6b.Total well depth: 12 (ft.) 1617 Mall Service Center,Raleigh,NC 27699.1617
10b.For lo(ecfion Wens: in addition to sending the loom to the address in 10a
6c.Borehole diameter, 2 (in.) abuse, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.W'aler level below ground surfw: 6 (D,) Division of Water Resourctm Undergroo al Injeetioa Coed"Program,
1636 Mail Service Center,Raeigh,NC 27699-I6316
6e.Outer casing length(if known):
1 .5 (RJ IOc.For Water Supply&Infection Wells: In addition to smiling the font to the
addtess(es)above,also submit one copy of this Corm within 30 days of completion
of well abandonment to the county health department of the county where
of.Inner casinWtubing length lif known): 00 abandoned'
6g.Scrern length(if kn.,,n): 10 (ft.)