Pasquotank_Well Abandonment_20230515

WELL ABANDONMENT RECORD For lMA:r'1,a Vw ONLY; �
� This form can be used for single or multiple weltsU
i
1.Welt Contractor Information: \ Wrl,t,ABANDONMENT D);TAIIaS
Scott'Bunt, Jr 7a.Number ofnell:i being abandauf-&
tiVcJl'Co,�racforAantc(gr�rillouurpCRar,ally ilt�nitaninrs�rEi.oetliisriterprapcny} fa' rrndrlFre 111fiain,r or ,nira-;lifer Arprh- walls ONLY will .11m wiie
corxatrrrerlwu;�t�auionnl,arr,inrvcxvr.rlh..�nNa,�;fnPAl,
4561-A
NC 1Vo11 ConlraaorCcrtis<cnliau Nnni+er 7b,Approzimr tc volume uf,,rage reinainin6 in well(* (laL)
SAEDACCO Inc FOR WATER SUPPLY WEL[.,S ONLY:,
CanaDanp Namt> 7c.Type of disinfectant used:
2c Wcll Coustructiore Penult
Liu rn4 u1tp11ab10 trrH perirritr(i.at C�ver1, Stab,1'uriarrce.Lr rcliuu,'rtrl+Jlu,r��rt 7d;_amount of disinfectant us�4l: MAY
'=
3.Well uw(cheek-well use): l►1+`Oi ;; Y
Water Supply Weld 7c Sealing materiels used(chcck all that apply):
❑AGricttltttral. l7hlttni ipallPttbsic Q Neat C6ntcut.Grout ® Scntonitc Ch)ps
❑Crsnthcftil(Hcatiuja Cooling Supply) ❑Resiftntial Water Supptl•(Single) ❑Sand Content Grout ❑Div Clay
❑irtdo5trialf(amntctcial ❑Residential Water Supplti,(sharai) ❑42borWte Grout ❑ Dn1l.Cultintrs.
❑hri tioir ❑ Specialty.Grout ❑Gravel
Nbu=Watek Sug}lmty Well: - 0 Benlonite Slitay Ct Other(explain under 7g)
I9lvlanitarine ❑Recovery
Injection Well: X For each material selected above;provide aotountof.materdaU need:
❑Atinikr licclarga OGromrdnalci Rentediation
❑AquiPeEStomge utklRectn'ety ❑Salinily Barrier
Bentonite.:901b ,Wtr:gal.
❑Aquifer Test ❑Stonnn'ater dnmiu:ige _
DExperitrieintrl Tuchuala v ❑Subsidetxo CorNro1 7g.Provide a brief description of the al►andmuncnt pcn_eedure:
Meolhemtal(Closed Loop) OTracer
well is located on the edge of body of water and during high
❑Geotheral tfieat)ng lcooflnRRetuml ❑Other(es lain under 7.R)
tide the well would be under water; pour bentonite pellets
4.DatC Well(s).4bapdooctl: 4-3-23 down til 3 feet below surface and topped off with neat
Sa.Well location: portland cement and the capped with concrete
USCG Base - Elizabeth City
FaciRiff,vrurNdnm Fxilitylps(ifappliraibic) S.Certifcation:
1664 Weeksville Rd. Elizabeth City, NC 27909 ��'� 4/21/2023
Pln•sical'Addmss.City,and Zip SigripiclorCertin;ytWe71(•onr.,raror Well Ohvrwr Moo
Pasquotank 1y sr}, h: q tkZs form, f hereby ceYifv thar the irell(s)ryas Overe)abmidoned in
('acrury' PsreelWenllllmtlan No.(M) 1wwrxlancztfrtli11-if VC,;1C:0J,,C,01 of)or2 .omoiFclJCur,structiunStimrrirrds
tmcl their a cppir of'Ehis recurrl has beo'x pruvitlerllo dre'tfell Owner.
$b.I:atitude and lnrlgitutte in degrceslntinnteskConds or dccim;ol-.dcgmes,
(ifneu f4id;omw 9.Site diagram or additioualt►.II details:
]'ou Elias'use Elie bacl:of thus Mtge to provide additional moil site details or well
A' W abauclanutemittit toils: You may afsa atlaelt trdditimtal panics if rmecessary-
CONCTRUC-110N nrTAIL-ti OF WELL(M BEING ABANDONED ; TBNtlTTAL INSTRI1CTTO:S'
:trtarlr trrll.rurxstn,c•11an ncLvtllst i�'avili&eriFu. !�w muluplc iltJrrUrart iv nun-u•crlrr mpp,}
11-CAY ONLY 106111x,Sam"cr+uuni.pom'r,t�mtoruuln�•r11.gnu can srrGtrcit'cute j'unrt Ift j(or.All Wells- Suhm)t this fort nit6in 30 days of eoinplction of bell
6a.$Yell ID€:12MW-14 abandonment to the rolloWlIk4;
DM Ann(if NVarei-Resaurc�-c,.Informutii)n;Proctl sing;Unit,
Itir 5:ri1 Sen•iee(;enter,Raleigh NC 2769'9-1617
6b.Total n'cll.depth: 42 �.} Raleigh,
10h.t;ttr infeelfort Wells: hr addiliou to seuding,the form to the address in 10a
6c.Rrrm eltola diameter.1 (in.) above.-afro subutil ona copy of this form within 10 days of contpleiiou of well
abandonment to,Elie falluWirmg;
641,Water lcvcl below ground sur•Puce:.1 (ft,) :Divisiutaof Water Resotir Ls,Uudergrouud In jet.•tCou Coutrol Program,
IG3fr Rlail Sertiicc enter,Raleigh,I\( 27699-IG36
6e.Outer easing length(if known): 10c,Fnr Watnr 5unnly IS injttion '_ilv: In addition-to standing the form to
the addresses) above.also submit one copy of this foatt within 30 days of
completion of,,veil ahandmirnent,to the county ltzatih depannicni of the coup;♦•
6t.Inner casinw+tubing;tength(if[Mown). (D) wilco abai4oncd.
6g.Sa&n length(if kamsn):10 (ft.)
Form G%V-30 North Camtim Departnxm afEnviroantew Ord Nmuin Resomccs-Division of Watcrifesolmes Revised Auk 20 B

i
NVELL ABANDONMENT RECORD For lntemdlVw-ONLY;
This forth can be used for single or multiple hells
i.Wctt Contractor infonnatiou: VVFLL ABANDONMENT DETAILS
Scott Hunt, Jr IL Nntrrber air liv ells beiu„alianduII ued: 1
Well eody actorhame.(ar ttellovrrer pctsoltatlk ul,indn;tlao NL'tl.al411LS1Iler prattelrY) Fern, rmdopre o fec:iwr or rwrJ-ri4ucr strirph- i<v/ts On), w111, .11,x! sruite
c•!NJsrrucoorvi,bo,xirvrnnrJt,lt,rr(YUP,I;J1LUf fYk<frr„t.
4561-A '
NC Wcr1 Svnlrtstortsrtifiwliota Nnniatr 7b.Appro-tunate volume of wahti;rt!ntjining in well(*'
FOR WATER.SUPPi..V WFLLS()Ni.Y: r~
SAEDACCO Inc +
Canryaa),Name ?-�4
7c'TypeMA
of disinfictarrt ulicd: �. J„� , ••
2:Well Comtru#•tiou P4!nuit 11:. V 1 ro 2✓72�
Lime l viiiihcoble rnefl;wraritr_p'.e.CuarJlr,Slm:,t'adarwe.kr;r doti,L�kI ttf kmwo
7d.--Uriutmtufd6hilectautusc4l: Intr:,-;
3.Well aye(check WL11®sc): 9'�+rx f,U.
Water Supply Well: 7e.'Saafing materials used(check all that apply);
[7Agrictlltora[: ❑municip.•d/i'tiblic ❑NcatCerticut.Grat to RcnionikChipsorNllcts
❑Grnlhennil(HcatinSIC.9oliri,Supply) ❑Iicsidtntild Water.Suppbp(single) ❑.San&Cenwnl Grout ❑ My Clay
❑luduAriWICbnmtctciai ❑Residentutl W;ucr 5npply(sharer) ❑Concwtc Grout ❑Drill Culdogs_
❑hri�utiair ❑ Specialty Grout ❑Gravel
Non-Water Supply NVc11: 0 Bentonite Slurry 0 Other(e {)lain under 7g)
MIJunitodire ❑Rmovery
injection Well: If.For each tuater'ial selected above,provide amount of:ruater'ials used:
❑Aquifer Recharge ❑Groundn;icr Rcutediation
❑Aquifer Storage aid Recovcn• ❑$alinity Barder
❑Aquifer Test ❑Slomnv'aterDrahtage Bentonite.:l001b ,Wtr:gal.
❑G-xpetinteuml T&Iwalogv 0Subsidet=Coauml 7g:Pittvide a Brief di"criptiau of the abandoninent.pnicedum
❑Geothennal(Closed Loop) MTracer
well is located on the edge of body of water and during high
®Geotherttra!(Ft�TtioPJCoolin>;tteturD} ®Other(explain utrder7 2
tide .the well would be under water; pour bentonite pellets
4.Date wcu(s)ahandoncd; 4-3-23 down til 3 feet below surface and topped off with neat
5a.Well location: portland cement and .the capped with concrete
USCG Base - Elizabeth City
racilityrUvvtsrNJutu Fxility ID9 Gfupplkablcl 8.Ccrelfi�:ttion:
1664 Weeksville Rd. Elizabeth City, NC 27909 4/21/2023
Physical Address.Citr,aid Zip SigrtSlnm or cud tried 1Wll Cut loklar(it Well Div,ur Utge
Pasquotank iV s%s z g this Jinn,, !lremby ceriifv cunt the a ell{:qi rres(were) m5ruidor,ed nr
Couaky Parrelldztuifk:t6Utt MCI,(PiN) wearrrianveivitlrla XCACO20,0101)or2C,0200rMillConsinictionSt'andarels
and fluTe a'CQp.'ir ofilri,V record has Iwo#pro' ided.ro lke well owner.
Sh.I atitudc and lond,tud-c in dclmees7ntiitutes/sccards or di�cim;d Acgr ms:
f(i veil read;otw L-100,l3iv iliTrex IA) 9.Site diagram or additiouatwell dctilbu
You,ivac tcse the back of this page to provide additional hell site details or well
N W abaudounteru details. You utai'also attach ttddititntal pates if r►ecrssan-
C(INS'rREIC TION DFTAILN OF VV1 LL(4l BEING ABANDONED S._ -
LIRAiTfTAi.,tNSTRtTCTiOLIS
:rirr,dr nrll.r�ras,rt,cliirrr r>:cvrri�'sl,if uvi,ilm5;c- 1�or rrutiiple i,fr[ffr,it iv rvrrJ-uxJ,!rr s„tp1r
1re11e ONtYtrrU,rlx savtecrrrsnrnroorn!�urelurrn<<ue_i+,rrcm, rdmir'mtefurrr: 10a; For All %V'eil.- Suhmit dais fhnn ilitldn 30 d:ts of eoitipletion or well
62,Well ID#•12MW-13 ibandotnuc.0 to the rol166nq; .
Division of Watcr RmourcLs,.Iufonnatitin:Procusinp.Unit,
60.Total well depth: 58
16 ' "17 Mail Senice Ccuter,Raleij-,h'NC 276; 9-I617
(fL)
tob.For inkeliorr«rrlls: In addition to scudirtg.Are form to ilia address in 10a
flc.l3otelrotcdi:tmctcr 1 {lit,) above.also submit one copy of this fotm%vidiin 30 trays of cutupletion of yell
abaudotmtetu to the following;
Division of Water Resounes,UodergNuud injection Coturbi Program,
fid.Water tec'cl belmt.grv►unct surface::1 (ft.) 1636 Mail Sei•sice(`octet•,Ralcigh,NC 27699-1636
6c.Outer casing lens h(if laow (rL) 1(lc.For Miter.St,Iytgly eF inlertlon Welts: lWadditian to sending the font to
the address(es) above. also submit one copy of this form within 30-days of
comptcdou of wdl abandoumcni to the county Itsatlh department of The County
6f.Inuer casink?ttt btnA teny-th(if imuwn): A)
where abindowd,
6,,Sct'een length(if imo%{u):10 (ft.)
Fence GM-30 Nanh Carallm Depannrem of llm trooment aul Narwal Resoluces-Division of Water Rcsou,Rs Revised Auguu If)t3

i
WELL ABANDONMENT RECORD For IrIcnitlUgdONLY:
This form can be used for single a multiple Wells
1.WcII Contractor Information: WELL ABANDONMENT DETAILS
Scott aunt, Jr. 7u.Number(if Nvells being alnandoned: 1
SYellCorA=orName(ontCllaM'arrpalaaltallyat>anIIdnlne%*LU.anhisiberprWrty) For umf0ple trfec4forr or rMa"roarer supph, malts ONLY tart!) t,m swine
co+s3trtrcnar'e7baammrorear, amrsnhnrltwrafonn,
4561-A i
NC Well ComraoorCcilifflm Naaftr 7b.Approximate volume of wattIa•remaining in vv'ell(s): (gall
SAEDACCO Inc FOR WATI£;R.SUPPLV WELTS ONLY:
Company Name 7c.Type of disinfectant used: f'^ r—
r••r �. n r,F-5,
2:Well Construction Per'tn[t 4:, � (t,• � �r�--5
Ihtadlapp1hobfeur11,wrjrrif(Ke Cuaao,Slal,Marfar&e,bbeafriV,.etc.J fktrrarou X Amount of disinfectant used:
3.$VCR uti(checli-Wen arse):
Water Supply Well: 7e.Sealing inatcriats used Nbcck all
❑AsricnittnAl ❑NcatCcmcut.Gtout ® 1.3cntonitc 6 aTAJl i
❑Crcothcnm.•ti(llcatineCool[no Supply) ❑Residential Water Supply(single) 13,Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(sha cd) ❑Concrete Grout ❑Drill.Cultinp
❑inia•lion ❑Speciidty.Grout .❑Gravel
NouAVater Supply Well; 0 Bentonice Shiny Cl O1her(exp1ainunder7g)
29hlanitorine ❑Rticoven'
Iujccdon Well: X For each nritteiial selected above,proside amount of.materials used:
❑Aquifer Recharge ❑Grutnrd%vater Rentediation
❑Aquifer Storage an i Recov cn, ❑Saliinav Darder
❑Ai)ttifcr Test ❑Slomnvvter Drairwge
Bentonite.:100lb ,Wtr:gal.
❑Exgerintettlol Technolog_v ❑Subsideme Conran! 7g Prnvide'a brief disciipton of the abaudonmcnt.p"we-dun:
❑Geothermal(Closed Loop) ❑Tracer
well is located on.the edge of body of water and during high
❑Geothemrat(Reati&Cootin&Return) ❑Other(es lain under7r,)
tide the well would be under water; your bentonite pellets
4,Date well(s)abin doacd: 4-3-23 down til 3 feet below surface and topped off with neat
Sa,Well 1pestion; portland cement and the capped with concrete
USCG Base - Elizabeth City
FLn:Ud),Xhv tcrNam i'xilit)•IDa(irapplicable) ti.Cerelliralion:
1664 Weeksville Rd. Elizabeth City, NC 2790.9 Q41. 4/21/2023
Pit}'sisal Address,City,wid zip Stert:tim:orCeairied Ivcll Car elor or W01 Owrur Mix
Pasquotank Il}+si�aun this form, I hemby certify that the trell{s)was pver4)abandoned in
Cauuty Parcel idaalit'q:than No.(PIN) acrxrrtlance with 15 i A'CXC 02C,0100 or 2C.0200 fE ell C•unsinlctivrs Sfanakirds
and drat a Copy ofilds record taus been provided to ke wall owner.
Sb.i ltitudc and Inngitude IIIdcgrecslminuteslsecands or decimal degrees:
prwell field,ow L-Mn lg to s,rrr;c erx) 9.Site diagram or.additionat well details:
You tuay use rife back of this page to provide additional hell site details or well
abandountetu derails. You may also auto([t aalditiottal pabes if nkeeessarv.
CONSTRUCTION DETAILS OF WELLfSI BEING:ABANDONED SURNIF PAi.INSTRUCTIONS.
:ttinilr rcell mrruuc•Jiart mcvrrt;'sJ Jf av�OJlr�ilr! lour multiple Jnfecfiura w rvn•uerJer su�plj -
11Y1£)QNLY rrlth fIFN:Sf7J11e fO1G5hLl"lJUIN�rLralWrr:i�ryra.y�rrr cant submit arelonm 10a, For All Wells Submit IhLS fnrni%iithin 30 days of corriplction of well
6a.`Nell 12t1W-13 abaodonmcnt to the FollOvving:
Division of�Vatcr Resources,Information Processing Unit,
6b.Total well depth: 58 (ft.) 1617 Mail Service Centcr,li:rlcirh,NC 27699-1617
10h.f nr infection Wells: In addition to sending like form to the addtess to 10a
6c.Borehole d[atucter:l (ire,) above,also subutii otte copy of this form withal 30-days of completion of well
abandottmeta to the fallowing:
Gd.Water level bdow pround mrfacc: 1 M.) Division of Water Resources,U.idersround Injection Control 1Prugram,
1636 Mail Service Center,Ralcigh,NC 27699-1636
6e.Outer eosin 1 • (fG) loc;For Mier Strmnly!& inirerion Wetly; In addition to sending the fomi to
g length(if ImrrU n) the address(es) above. also submit oiie cop}' of this fomi within 30 days of
completion of ivell abandountent to the county health department of Itie county
6f.Jfnmer e:rsio,tltub[mg leny,Kb(if tanorin)h (ft.)
whcrc abandoned,
6g.Screen length(if known):n):10 (ft.)
i
Fano G%%141 Nardi Camllm Dcpannw of Ettvironnrent aril Natural Resomces-Division of V,'iter Resorrrne Revised August 2013

i
WELL ABANDONMENT RECORD For lmc alUscONL1:
Ws form can be used for sitggfe or multiple wells j
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott Hunt, Jr 7%Number afnella being nbandam:d: 1
%Ve1U6r1ractor Name(or well onuerpersan3ll)ab=Mning nell an histher prepeny) pa• widople 7ri;ernair dr rera tr,i'ter suprly wells ONLY W16 11m some
c�>rulnrccwi.�6arttlaitnacRir,}na our=1i mnateform,
4561-A
NC iVcll Ccntreaor Ccitifccmion Ninrbcr 7b.Approxime rolume[if water re
maining emaining in
SAEDACCO Inc FOR NVATF.R SUPPLY NVEL S ONLY.
Caaripauq Name 7r;Type of JisimfiMtamt used: FR _• .„ "`
2.well Coustructfon Pcrmif 9., MAY 1 `�n
Lwall appL4vble weldpurmri.r list Cw,uo,Stale,)iriattce.bbecwat:,etc)f t wLvri 7d.Atuattat of disinfectant used 5 2Q23
S.Well use(check-wen use): l r £
Water Supply Well: 7c,Scaling materials used(check all that apply);
❑Agrirniturtt ❑Mtmidpal/Pttblic ❑NGtt Ccmcnt Grrout ® Scraonitc Chip§or Pellets
❑Geotlterrnll(HcatinglCunlirig Supply) ❑Rcsidcndat l atcr Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Induslrial/CoE mor ial ❑Residenthd Water Supply(shariod)" ❑Concrete Grout ❑Drill.Cultings
❑Irti lion ❑ Specialty Grout ❑Gravel
Non Water Supply WcB: ❑Bentonite Slutry ❑Other(esplainunder 79)
MNIordtorhre ❑Rccover_v
Injection Well: 7 f.For each matetial selected above,proside amount of.materials used:
❑Aquifer Rcchacae ❑Groundwater Renlediation
❑Aquifer Storage aid Rem,cn, dSalinity Barrier
,
❑Aquifer Test ❑Slonmtmtcr Dnritwgc Bentonite.:201b Wtr:gal.
011vtrintenutl TkItuolokn• []Subsidence Corxml 7g,Provide a brief description of the abandonment-pri cedure:
❑Geotheetntal(Closed Loop) ❑Tracer
well is located on the edge of body of water and during high
❑Geothermal(HeatinNCoolin Return) 00dicr(x lainunder 7u)
tide the well would be under water; pour bentonite pellets
4.13atewell(s)ibandoned: 4/3/23 down til 3 feet below surface and topped off with neat
SA.Well hrcation: Portland cement and the capped with concrete
USCG Base - Elizabeth City
Facilk/fh tvrNmw rXitity IDd(Ifapplicablc) S.Cctllticutipn: I�
1664 Weeksville Rd. Elizabeth City, NC 27909 ��'� L 4/21/2023
PitysicalAddres,City.andZip Sigcit,lrcorcgoirX4 Well O,nr arorWellChvmr D,ue
Pasquotank 13y signing IhO form, I hemby,certify, Thai ike u•ell(v)ryas prere)abmidoned in
Cmto(ti Pxcc1 No.(PIN) accwnhruce with I M CAC 020.0100 or 2C.0200 IFel1 Construction Slarukirels
and dral a copygfdds record has been provided to fire well owner.
5b.Latitude and longitude in degrtceslmirtums/seconds or decimal degrees:
(Ifivcll told,ow Lltjlang isiitlrlcicni) 9.Site diagram or additional well detalls-
You ttlay use Elie back of this page to provide additional well site details or well
N W abandoniltetil details. You tuay aLlo atlacit additicttal pages if ibeccssan,.
CONSTRUCTION DETAILS OF WELL(%BEING ABANDONED SUBMITTAL TNSTRUCTTONJ
Affilill ire/)romstrmclien recvrd(s)if avaiul" Far 11rultiplr bye.0 ran or mnordlr Supply
u,elleONLY nirli llk.sauteeOirsL7A2noir of iltrtlallm 7n.iwa catl3trLmfl rmrel inrc 10a.Yar All Welk. Submit this fomr within 30 days of completion of mall
6a.Well IDf1:
12MW-SO abandonment to the followigg:
Dirisian of Water Resources,Information Proctessing Unit,
6b.Total well depeh: (fr.) ' '
1617 Mail Service Center Ralei„it NC 27699-1617
15
19h.r r Tnle-elion ells: In addition to sending the form to the addtess In 10a
fie.Eloeehole dlaumeter.1 fin,) above,also submll one copy of this form ni(hiu 30 days of completion of well
abondonnicni to die following:
Division of Water Resources,Underground Injectlon Control Progratu.
6d.Water lend below ground surface: 1 (fW 1636 Mail Scrvicc Center,Raleigh,NC 2 7 69 9-1636
Gc Outer casing length(if Imr;mm n): (fG) 10c,rnr\Voter Sunniv&hdectfnm WON: In addition to sending the fomr to
the address(es) above. also submit one copy of this form within 30 days of
completion of well abandonmem'to the county lreafth depannteni of the county
6f.Inner casing/tubing length(if lmawn): (ft.) where abandoned,
6g.ScrvLn length(if 1mown):10 00
Farr GW-30 Nonh Carolina Deponamcra of Envlron mment and Naturat Resoumcs-Dh'ision of Viater RC o1ucC5 Revised Aupu58 20B