Pitt_Well Abandonment_20240423 (2)

WELL ABANDONMENT RECORD /P Rr Ilan!use ONLY:
This foiin catibe used fbr single.or multipleNfells-
A.W01'Contractor informadbn: WELL ABANDC}NhiENT DCTAIEe�
Stefan Smith 7a:Nutgtier it wells being aliand!mi41: 1
N1'ettCoryraclorNanrc(glHaltlON'M1�7CRdrL7tJY�f�35L�011J11�1Ritl.OrltLL4Jllarp70pCltY) YeU• tindripfe litlevHM or'• abx4ater supply welifs-. ONLY wtali .11,0 s ie' -
' cori's7rreraaararbojz<frNrxac�rat-�necara7atvaritialefnrnr, -
3576A
NC�Ven'Com>aporCeuifi@atiuu:htniiabct
76.Appn)ufmate vnlnmc of-*at I n maining inNi'ell(sj?1 (g il,}
SAEDACco 'FOIL WATER.SE)I'Pj V.WELLS ONI,.Y:,
Caatagany Namo 7c.Typr of disiufivtant used:
2:Will Co»siructfanPumit fl:. WM0701315,.
Lurrdlnlr<al.amLlcurtllnaavitrry.aGwrarv,Sraitz.d'urtrirtic;I�ritlori, trafka�ramra 7d;AitnittnQot&-lnfeetstutused:
3.Well usi(ekvii welt use):
Water Sttpply Well 7c,Scaling inAtcri46.uscd(cbcck aiftiiat apply):
❑ASranituial, pTvftinicipalEPtibiic 0 -Scaling
Cenlcnt.Grout iN Ecr ooilc Clips or Pcllcls
OGcolht rmat(Hcati4i Coolitig Supply)' Mesidcntiat%V.,jtcr.Stippb:(single) El Sand Center:Grout ❑Dry CL-ty
[7haduslriaUCortii►rceCi�l ❑Rcsicfcmial tVatcr Stirppf}'(s�atrd) b�nccete Gniyr, O Ddll.Cituitit s.
Ohcf tioit ❑Specialty Grout .O Gr.,vel
Nan-Water Suppl*Well. O Bentonite hi* O Other(esplaiii udder 7g)
F9hfanitorine Olkwo%,ery
Injeetivn Well: X For each tuaterial selected abavie pro%lde atuounEof.matetials used:
L1Agirifer lYecltadQ�c OGigtttuivtaler RemedisUion � -
OAquWr S0mgC ars l.E&oNvery OSaliirity!tarried
• OAquifePTes! OStonmvaterDiuiaaige'.
Bentonite.:31b ,Wtr:gal:
L1EVerimental TMInotogv 1ISubsidence Conlml '
[1Geothennal(Closed Loop) ClTracer 7R,-Prirrid6 a brief dcuription of the abandnnmcnt pniectilun:
Pour
®Gtathert"alt catd NCadtinaReturn) • 130lhcricx lainuudcr7 ) t- ►.._ .ir=^ : �`
r
.:.hate We-tt(s)abarri(loncrl
3/12/24 2822
Sa,Well taeation: ;.a,- .E7,7'7,4 '�d
Speedway 8293
taciltilrlYavncr Narrrc. Cs Jlit�tDp.(ifapplicabld► 8•Ceillf eadafr:
612 Sk Greenville-Blvd Greenville, .NC 27858 jI.�Yt 3/26/2024
Physical Address:City,and Zip St-Ftlase.-..Cemiucd Well Coacrrcror br Well Owwr Digs
Pitt .
-lid?sagai?q this fhafx, I hereby eerlify•flan the tivelf{'s}n as ltrea z)rn5imdauaeri in
C ouu[i Pan:cl fdcaflf6mtlon Na:(Plat) r9xbrclrifacc irate IJA A'C�IC 02C i0160.arr X.0200 Well L'Uraslauclibfa SYcaWkarils
marl llrarJ,ai oPPt of{Iris_"iecord.ltars beeia provided fo drs treil Owner.
Sb.I.atittide and longitude in dcgre&0Ilnuteslse6nds or decintakdegrccs; I
(ifna:t1 roki,oiaa l..aUM'n��s sirtncia. 9.Sitc diagram or:additionat Nfcll�ctills-
3s.s72488 77.398270 , loq iti*.Itse Elie back of tlils 0.90 to.provide additional Well site details.or iwll
T �� abaudountent deWfis: You inay ulso altach additional papas if iree'essarv_
CONSTRIJCTIOtY.DE TAILS OF WELL(5}BILINC ABAND6NED SUHNMTAL iNa UC,TiONcs
;11fu�r vic!l.ronitraacliutl,ralcwai'ts!'J)'avrtllahFr.:I'w'arrliJhplr brlrtrtar,i�rrwu•uxatrr strfgi/j � .
uelk OAF.YtrJUialaeaeui�+c iusravrtawr+afrmrakax!irwL_r+aucurss�rL,ra't'rxteliainr• 10;1:.For All Wells: •Submit f L.. ibtm uithhi 30 djys..'of of u-611
6a.Vr'c11.ID�•�-1 '
ibandontttcrat to the fal6vfllg: I,
I
Division r f Water Resuyrr: .Informatiiin:Proe&!Ssing Unit;
14 1617 Alai)Service Center,Raleigh,XC 270!1-1617
Glt.Coat tNcU•tloptlr: ([1)
10h.)-1 Inicetinn Wells: In-additibu to scoding ft form to the address in 10a
aboar:.a[so submit bite copy of this form wiihhl 30'days of cmuptetiou of N4ett
6c.:Bareltole.diameter:l 4�u.) abandomirciu to.tfcc,follawing: ;
II,
fitl \Voter[ccel hc[rin.gtband stlrfaee:. (ft.) :Division of WaterResourccs,Under&6uud lnjey't[on eouuvl Mgrapt.
1636 Mail Scnicc Center,Raleigh,Ntc 23699-1636
y - 10c:Lar 3Var . conic. ' in(ecfliin��q'Rs: In additian•to sending the form to-
6c.Outer ming length.(if.lotown): (fL) the.addn:ss(esl above.also subnlit�bile cop}- of this fbrm'tvitiiin 30 da)•s of
comptction oftrell-abandoluricntltmthecounty health-deliaaricncrd of the concity
«lino abandoned, I'
GL Inuer.eariu;.tubing tegnhi(if lalown)i (ft.)
6g.Screen length(if known):s
Form GtV-3a -Northh CamHm Depannrcm ofEndruoancnt aril N aum Micsoorcs-Divislan of WiterAcsou=s Revised Auga 2013