Pasquotank_Well Abandonment_20230515 (2)

WELL ABANDONMENT RECORD For ls»cmalliscONLl':
This form can be used for single or nitiltiple ivelis
I
1.Well Contractor Information: WELL ARANDONMENT DETAILS
Scott Hunt, Jr 7a.Numherofi'vells being abandoned:
Y 1
�c &n]r1tacroiName(ortrcllu%ercr pceianalty:tiank3difaxtiau an For niulnple Pryecttar OP supjA, walls ONLY will) Av sane
eorufftrcf)aum6,utlmrmcaf,ir,rre�urr,rihnur ixjornt
4561-A
NC iYc11 CnntraclorCcriificntioa Nmabcr 7b.Appruximatc vohrme of water rcmtrining in well(a): („aW
FOR WATF,R SUPPi Y WFLL.S ONLY: _
SAEDACCO Inc �.
Company Name 7c.Type of dhinfectant used: .�4_ • "a "?.
2.Well Coasuuction Permit M:. MAY
11sf a�1 rrppflauGle urll iurmiir{,.e.Ccunrr,Sra1�,)uriarre,brfecdiva,e/C}f R/IU�tri 7d.�Un0atit of disinfl&-tant used: � � 202
3.$Veil Use(check-well use): i J7d'=i`:'� ,i. �;S�•4Y'r..
Water Supply Well:, 7c,Salin materials used checG all that aPPIS.),• G. ` `.� 3 l:r;;1
❑Aoricultttntl CIMunicipal/Kili is ❑Neat Cement Grout ® Rcntonitc Chips or Pellets
❑tacothcrmil(Hcatinnf Cooling Supply) ❑Residential Water Supply(sinplc) ❑.Sand Centent Gmut ❑My Clay
011415J iallComntcrcial ❑Residents.'itWatcr Supply(sh.•arcd) ❑Con=teGrout ❑Drill.Cutdals
Mitigation ❑Specinity.Grout ❑Gravel
Non-WatcrSuapph'Wcrl: ❑BerrtouiteSluay ❑Other(explainuoder7g)
99maniloring ❑Recovery
injection Well: X For each materfal scleded above,provide amount of.materials used:
❑Aquifer Recharge ❑Gmunduater Rentedwtion
❑Aquifer Stonige ark]Recovery, ❑9alinity Barrier
❑AgpiferTest ❑S.tortinvaterDianage Bentonite.:301b ,Wtr:gal.
❑Expetinteatal Technology ❑Subsidence Conical 7g,Provide a brief description of the abandnnmeatpirvicedurc:
Meothern at(Closed Loopy ❑Tracer
well is located on•the edge of body of water and during high
©Geothemtal(IiettiLW2oliu&Return) ❑Otiter(e:c lainunder7 )
tide the well would be under water; pour bentonite pellets
4.Date well(s)Abandoned: 4-3-2 3 down til 3 feet below surface and topped off with neat
.;&Well location: portland cement and the capped with concrete
USCG Base - Elizabeth City
Facf1Hyi4hvm,r Nmtic rxilrty IDb(ifapplkablc) $_eCl�et7iRrttiou:
1664 Weeksville Rd.. Elizabeth City, NC 27909 `-'� 4/21/2023
Physical Addtcss.City.and Zip 5igmlam arCeniried welt cn,10fonr or Well Onnr Dille
Pasaotank lij:.sjgnhis this form, I hemby certify that the we11(i was prere)abandoned in
County 11`4cel ldcarifR,.itina No.(PINT =vnlance ivilh ISA Vf,[C 02C,0100 or'C.0200 I Mull Cans'tnictluu Start&irds
and ilral a Coptrofiltis record has been provided fo ilia hell otiver.
5b.Latitude and longitude in tlelTe (minittes/seconds or decimal degrees:
(iftvcu 64d,one 4uAoug ts.inffrtiant) 9.Site diagram or additiouat well details:
You tuay use the back of this page to provide additional well site details or.t<ell
lr� W abaudomrtetu details. You may also attach additional paves if necessary.
CCONSTRII(MON DETAII S OF WELLt.51 BEING ABANDONED SURN11"T l•Af.1N.STRUCT. iO�TS
Affade well cnrrsiruciiora recnrrlt)if arailrsrile.. For)mJ6ple it f'eefion or raonnivler•supplj,
aelk ONLY trNk rlu cau suLmit are fanri 10a,.For All WeIN Submit Iliac font within 30 days of completion of well
6a.Well IDS:
12MW-11 abandonment to the followirrx;
Divisida of�Vatcr Rr tmrees,Information f rocemink Unit;
6h.Total well depth., 27 (ft.) 1617 Mail Service Center Raleigh,NC 27699-1617
tOb.):opt Inlcetlon_Wells: fn addition to sending the form to the address in 10a
Ge.Iiorehole diatnetet:l (ill.) above,also subutil one copy of this foan within 30 days of completion of well
ubaudotmunt to the following:
Division of Water s,Underground Injection Control Praigram,
Gd.Water level below ground surface: 1 (ftJ 1636 Mail Service Center,Raleigh,NC 2 7 69 9-163G
Ge.Outer casin if k (ft.) 10c,For Writer Stmniv&ialectfnn MIN: in addition to sending the form to
]:length(if the address(es) above. also submit one copy' of this font within 30 days of
completion of welt abandonment to the county health department of the county
Gf.Inner casinWtuhink tength(if lamvrn)r A) where lbandoned,
Gg.Screvit length(if known):5 00
Fonn OW-an Nanh Carotim Depaninem ofErwirotutient and Natumt Resources-Divisfon of Winer Resoar s Reviied August 20B

I
1VE LL A,DAA,NDONN ENT RECORD Far Irdemal u-4 MY:
This form can be used for singre or multiple ivells
1.Well Contractor information: WELL ARANDONh1ENT DETAIF:S
Scott Hunt, Jr 7a.Number ofi*YLA%being abandoned: 1
`�'cllCodmnorNanu (or�e�lloxrsrpcasanatJy il:aoatonlnnuetlanli�tlacrpropertyl FM- nradople uvjvioar or wwj-'ra(er strpph, "ells ONLY wall Mw smie
cnrr;mrcnwa.•ivarclaura*ar,�r�a cxor aatvnirarsjnrnr,
4561-A
NC 1-Conlragor Ccnifi ition Non bcr 7b.Apprnximitte volume of watu r:intainin-,in w•ell(s):.
SAEDACCO Inc FOR WATF,RSUPPLV WELLS ONI.Y:
Cang+any[+tame 7c.Type of disinfectant•used:
2.Well Construction Petmlt ff-,
LCtt rdl altliliaxrbh urlllnrmidv(i.Q Crcarrir',Stutz,i iaraarre,Lrjdcii'na,.c7c}lfkaruwn 7d.Aui6tmt of dlsiufectaut used.:
MAY
3.Well usi(ched:hell use);
Water Supply Well: 7e.Scaling materials uscd(chcek all that apQ�)•i;trrs:i^� i�r ^;,.h,;,; Ur;':
MAgriculturat ghlunicipalMoblic la,Neat CcmcntGrout M ScronumIjis`i1RSPylltts.
❑l;rolhcrmal(ticatineJt:ovliugg$apply) ❑Rcsidcruial�Vatcr Supply(single) ❑.Sand Centent Grout ❑My Clay
❑IrulostriallComincrcial ❑RcsidentfalWatcr Supply(sltamd) ❑Concrete Grout ❑Drill.Cultitip .
❑Inn lion ❑ Specialty.Grout ❑Gravel
Non-Water Supply Well: M Hentouite Slurry ❑Other(explain under 7g)
Manitoring ❑Recovery
Injection Well: 7R For each material selected above.provide amoani of materials rased:
❑Aquifer[recharge ❑Groundwalcr Remediation
❑Aquifer Storage and Rem cry ❑Salinity Darrier
Bentonite.:301b ,Wtr:gal.
❑ ip iferTest ❑SlonmcaterDrsnrnge
❑Expt rinteilal Tec:haologv ❑Subsidemd Catdtul 7g.Provide a lull description of the abandonment procedure:
❑Geothennal(Closed Loop) OTracer
well is located on the edge of body of water and during high
McotheFfital(Hodag/Cooti D&Return) ❑athcr(es lainunder7 )
tide the well would be under water; pour bentonite pellets
4.13atewell(s)abandoncd: 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
Facilityi(hvnv Nmin rXility ID9(fapplicablc) 8•Certification:
1664 Weeksville Rd. Elizabeth City, NC 27909 �� 4/21/2023
Physicat'Address.City,andZip Sigrolow orCed tried Wc31Cou(.iororwolON= Dille
Pasquotank fly sign iqg this form, I hereby certify that ilte well(s)was(mere}abandoned in
Satmly Parcel Idenlifi6dan No.(PIN) aeconlnuce lVilh 15.1 A'CAC 02C.0100.or 2C.om r en Ca;asirucaon Staurkirds
and drarl a copy of llfis record kaiy beers provided 10 eke well owner,
5b.Latitude and longitude in dcgrcestminuteslseconds or decimal degrees:
(irwell CiW'011C la0011a is i1riftcicttf) 9.Site diagram or additional well details:
You tuay use the bawl;of this page to provide additional well site details or well
N W abandonment details. You tray also a ilaelt additional panes if necessary.
CONST1111 "PION DETAIL-S OF WELUS)1111M,ABANDONED SURNITIFTAF.IIVSTRCTCTTONS
:lHutfi well romrLmetlou mcnrdfsl if maolluble. Flu•aaalliple i;yec irm ar mn-irate r.wpplp
wells ONLY n•uh rite svute cruutrrrrrlotn'afrcuarh annerat-ioa edu srrbmlt and fonm 10a. For All W&-. Submit Ihrc famt within 30 days of cohiplction of well
6a.Well IDd:
12MW-22 abandoritncnt to the foll6ving:
Division of Water Resources,Information Processing Quit,
6b.To tat well depth: 30 lft.) I617 Mail Service Center,Ralei„ly NC 27699-1617
10h.For Infection Wells: In addition to sending tik'forth to the address In t0a
fie.l iot'ehole diameter.l pu,y above,also subutil oeic copy of ibis form cc9dlu 30 days of completion of well
ubaudountent to file follohing:
6d,Water level below ground surMcc• 1 (ftJ Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2769) 1636
6c.Outer casing Length(if Lvohtt): (ft.) 10c.Fnr Witter Sunnly&infection W&g, In addition to sending the font to
the address(es) abode. also submit one copy of this form within 30 days of
completion of cell abandmunene to the county health department of the county
6f.Tuner easinWtubing length(if tarown): (ft.) tvhcrc afxtttdotccd,
6g.Screen length(if talon n):
Fom GW-30 Nonti Caratim Depannrerd of Environment and Nauuml Resounes-Dh•isiaii of VJatcr Resoum:s Revised August 20t3