Pasquotank_Well Abandonment_20230515 (3)

WELL ABANDONMENT RECORD For lmemalUwONLY:
This form can be used for single a multiple Nvells
1.Well Contractor Information: WELL ARANDONh1ENT DETAILS
I
Scott Hunt, Jr 7a.Number nf wells beinkabandaned: 1
W01eantrnaortlare(orricltonp"Nmanallyahanfoninouellonlii herprogeny) Fw- withipte trJerifrur o rwalinifer sirlyt, walls ONLY wib tree scone
c�rLfnceftalhrbaarntwutn�it)ran a;rui,ralkntratt farm,
4561-A
NC We11 ConirdctorCcrtirttcation Nnnnbar 7b.Aplinrumsnte volume of rvahr remaining in well(s)-
SAEDACCO Inc FOR NVATF.R,SUPPLY WELLS ONLY:
Company Name ° ti4
7e.Type of disfuk�r�used:
a,� ,
2.Well Cunstruet[on perBllt a:, MAY 2(l23 list r.Jl rrpplkv6l�urllpvmity ti d.Cevarah:5t�Ye,Parlrtme,Lraclinrr,N1C}flGtrata 7l 5
7d.Amount of disinfectant used:
3.Weil use(checkw•ell use): ::., : ; .:. 3sr• t,'1
Water Supple Well: 7c,Scaling materials used(cinccic all that apply):
v:I �i�Ir
❑Agricultur tl ❑municipaMi fic 17 Ncat Ccmcnt Grout. ®13cmonitc Chips or Nllcts
❑Cicotltcmmal(ElcaiigrtCaoling Supply) ❑RcsWritW Water Supply'(single) ❑ I Cement Gmut ❑Dry CLiy
❑[ndustriMICommcrcial ❑Residentsnl Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Ins tiou ❑ Specialty.Grout ❑Grivel
Noll-%Yatcr Suiiply Wcll: 0 Bentouite Slimy 0 Other(explain under 7g)
Monitoring ❑Rix;overy
injection Wc11: X For each uraterial Selected above,provide amount of.materials used:
❑Aquifer Recharge ❑ roundwaler Rentedialion
❑Aquifer Storage and RecoVery ❑Saliniri Bonier
Bentonite.:17lb ,Wtr:gal.
❑Aquifer Test ❑ tornluter Di-simee
❑Esperinterual Technology []Subsidence Control 7g,Prnvidi a brief description of the alm ndunment.o.rriccdure:
❑Geothemtal(Closed Loop) Mracer
well is located on the edge of body of water and during high
Meothennal(HeaftCooLipi Retuml, ®0thcr(ei lain under 7 )
tide the well would be under water; pour bentonite pellets
i.Date well($).aumndoned. 4-3-23 down til 3 feet below surface and topped off with neat
55L Well locution: portland cement and the capped with concrete
USCG Base - Elizabeth City
FacsliWChvtwr Nmtw Fxildy 169(Tapplk iblc) 8.Certification:
1664 Weeksville Rd. Elizabeth City, NC 27909 c�'�.9eurt- 4/21/2023
Physical Addwm.City,and Zip $iffzjt11rcctrCcttiGcd W911(�mtt nr orWC31 olvmr D:ue
Pasquotank H siVnitis this form,,I hereby certify dint Ilse wells)Was(here)abandoned in
Canoly Patccl ldcrllfi.ciilaallo.(PIN) acconleince nvith MA CAC 02C,0100 ur 2C.0200[Pell Consintudou Starukirds
and that a roprofilds record has been provided to tire hell olvtaer.
5b.Latitude and longitude in degrtceslmlctutestscconds or decimal degrees:
(ifivcu rbW,OuL NYlong is suf smiy) 9.Site diagram 4r.add[donal well deE.11fs:
You mu v use the ba&of this page to provide additional well site details or cell
N W abandonutern details. You«ray also allach additional papzs if necessary.
CONSTRII(MON DETAILS OF WELL(%BEING ABANDONED SLIRbi1TTAL INSTRLIM. ON5,
`ftfach well enmu•uetiou reevril(v if Lmall ble. hisr tmJGpte i)Jrrrion car ma-11tinu'supply
wells ONLYlrlth ilk swiae callsnharalcurefiinc 10a: Fnr All Wells: Submit Ihic fame within 30.days of completion of well
60.Well ID0:12MW-23 abandonment to the follo%iag:
Diyisian of Water Resources,Information ProVessiag Unit,
6b.Total well depth: 30 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b,FnM Inleetian We11s: In addition to sending The form to the address in 10a
6c.Borehole diameter:0.75 (ill,) above,also subintit one copy Of this fanln%ilhitt 10 days of completion of w•eil
abandonment to the following:
1 Division of Water Resources,Underground Injection Contrill Program.
6e1.Water[cvcl hc[ow ground surrace: (ft.) 1636 Mail Sothic:Center,Raleigh,NC 27699-1636
6c.Outer casing length(if Imnwn): (ft.) lOc Fnr Water S agIft&[u[cctfnn 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%yell abandanm.nt to the county health department of the county
6f.Inner easinWtuhiur lcn:4h(if[mown): where abandoned,
ft Screen length(if hnotvn):5, 00
Fomn GW-30 Nonh Carotim Deporunord of Environment and Mutual Resoiares-Division of Water Ruotuces Revised August 2013