Pitt_Well Abandonment_20230327

WELL ABANDONMENT RECORD For Internal Use ONLY:
I.ANN ell Contraactor Information: WELL ABANDONMENT DETAILS
T✓A-A ll. 8'eckC 7s.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hi.her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
3, 2 A wells abandoned: f�
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): r� y (gal.)
A rn G D yv-T FOR WATER SUPPLY WELLS ONLY:
Company Name
t 7c.Type of disinfectant used:
2.Well Construction Permit#: N A 2023
List all applicable aryl construction permits(i.e.WC,Catn(v.Slate.F•ariance,etc.)ifkaoww
7ti Amount of disinfectant used:
3.Well use(check well use): DI ':J 4
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Gcotthertnal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑IndustriaVCommercial ❑Residential Water Supply(shared) 10 Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slu
rry ❑Other lMlaiq under 7gl
onitoring ❑Recovery
Injection Well: 7f.For each material selected
2boveI,provi�amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation A3 1)OS d- � a1AA J� CIQ.❑Aquifer Storage and Recovery ❑Salinity Barrier ( r 3 gG`�eMS
UAquifer Test OStortnwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ,Tj)�}�-t�
❑Geothermal(Heat Coobn Return) UOther(explain under 7 )
4.Date well(:)abandoned: �U p tk art 1or',J1 oil W04W
5a.Well location: 1 ' 1tn��/
Set(A� T t���{ o• D 3 b-2 8 i t
Fac lity/(honer Name I Facility[DO(ifapplicable) 8.Certification:
SbCo$ PC, NWy 33 9• 6 tt+,o ilk, I OC, 7b SE, Ir��A/ �-• (7, Z3
Physical Address.City,and Zip Signature of Certified Well Contractor or Well Owner Date
Po li S_&O' 7 l p ` )as 5 By signing this form,!hereby certify that the well(s)wits(were)abandoned in
Canty Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irwell field.one lavlong is sufficient) n 9.Site diagram or additional well details:
3S. S b 3 N 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 constnwiton record(s)ft'available. For multiple injection ornon-watersupplr wrlls
ONLY with the same construction%abandonment.you can submit one form.
yy��a 10a. For All Wells: Submit this forth within 30 days of completion of well
6a.Well IM: ,•`" � 3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: I (ftJ 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (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: ' ' Z (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Senice Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): I H (g) 10c.For Water Suonly&Injection 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): (fL) abandoned.
6g.Screen length(if known): M)
Form GW-30 North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016