Pitt_Well Abandonment_20240903 (3)

YELL ABANDONMENT RECORD for ltucrnalUscONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
7s.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same
wen Coneractor game Ior well owner personally abandoning well on histher property) %veil construction depth,only I G1V-30 is needed. Indicate TOTAL NUMBER of
%tells abandoned:
vC wettC6ntrac Certification tiund cr 7b.Approximate volume of itater remaining In well(s):
0 ►1Ci / . FORN'A7'ERSUPPLY1VELLSUNI,Y:
Company Name
��t� O t 7e.I �� Type of disinfectant used: _ /�•�/..,.�
2.Well Construction Permit tl:
Cut ail upplk able uelt coastrucunn permtp I6e,U t.Counn•,Srale.I ithaace,c-tc.J ifknacerl 7
7d.Amount of disinfectant used: 41-
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
OAgricultural OMunieipal/Public 0 Neat Cement(trout XBcntunite Chips or Pellets
G(icothertnal(Heating'Couling Supply) >(Residential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
D Industrial'Commercial OResidential Water Supply(shared) ❑Concrete Grout ❑ Drill Collings
+gs
glrri ration 0 Specialty Grout 0 Gravel
Non-Water Supply Nell: 0 Bentoeile Slurry O Otlrer(explain under 7g)
pNlcmilonnl• ❑Recovery
Injection Nell: 7f.For each material selected above,provide amount of materials used:
❑Ayuifet Recharge OGroundwater Remcdiation
ClAquifcr Storage and Recovery OSalinity Barrier
OAyuitcr Test QStor il%vatur Drainage
OExpenmental Technology OSubsidciweContro)
7g.Provide a brief description of the abandonment procedure:
0(icothernial(Closed Lcxip) OTracer
0(icothemia)(Ilcatim;iCooling Return) 00ther(explain under 7
4.Date well(s)abandoned: 1
53 Well location: : -
�OI I J7Y�Ie Li
f•acdity(heixr Name facility 1Dp(ifa(ry)licablc)
k.Certi cation:kk_ zr z"Ar
�.
)
lthy,icsf Address.City,and Lip S cure well Cnatrador a Well Owner [bte
,] signing this Jorin. I hereby certh'that(he imfits) leas(were,/abandoned in
County I'aiL.)ldcntificalion No.(PIN) accordance with J5A:VC.4C 02C.010I1 or'2C.0200 Well Construction Standards
meet that a coj,1,of this record has been provided to the well owner.
Sb.Latitude and longitude in degrecslnvinu[cslseconJs or decimal degrees:
iifa.11 lid.mr tati,nir,is sutTicic sl a 9.Site diagram or additional well details:
� � � � \ � � You may Use the back of this page to pn»•ide additional well site details or well
abandonment details. 1'ou may also a'tach additior-al pages if necessan'.
CONSTRUCTION DETAILS OF N•ELLIS)BFING ABANDONED SUBMITTAL INSTRUCTIONS
anarhucf/amrtractioarreordlr/ifuvailnh/r Piuvuu/lip/cinjcrtieatordon-uutrrsupplrnrils
ONLY with the.came ronslrh lion abandonment,you can submit one form
10a. For All Wells: Submit this, form within 31) days of completion of well
62.well ID#: 441,4 _ abandonment tie the following:
Division of Water Resources,Information Processing Unit,
6b.7 oval wcil depth:- -(ft.) 1617 Mail Service('enter,Raleigh,NC 27699-1617
lob.For Injection Wells: In addition to sending the form to the address in I0a
6c.Borehole diameter, 4� (in.) above. also submit one copy of this form within 30 days of completion of well
r abandonment to the following:
6d.Water level below ground surface: !V (ft.) Division al A'ater Resources,Underground Injection Control Program,
1636 Niail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(U Lnow n): 1/1 J' 10c.For Watrr Suppiv&Injection Wells: In addition to sending the I'omi to the
addicss(cs)above,also submit one copy of this form%%ithin 30 days of completion
of well abandonment to the county health department of the county %-here
6f.Inner casing/tubing length(if Wov%n): (ft.) abandoned.
6g.Screen length(if known): L( r l I1(}U.},\ (ft.)
Fonn(iW-30 North Carolina Department of Ent iromncnr tl Qua@p,-Div ttitni of Watcr Resourcc, Revised 2.2'2016