Pitt_Well Abandonment_20220531

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well o trac for Informafion- WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Wel(Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well ntra for Certifi tion Num�be�r� 7b.Approximate volume of water remaining in well(s):,
cow FOR WATER SUPPLY WELLS ONL
Company Name ✓✓ 7 ;K•,�
7e.Type of disinfectant used: V��
2.Well Construction Permit*: t V �o{ V w O -I
List all applicable well construction permits(i.e.VIC.County.State.Variance,etc.)ifknown
7d.Amount of disinfectant used: MAY .� 1 2972
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that aPPY InforvQUon Prac=gi g Unh
D'•°W60G
❑Agricultural ❑Mu ipal/Public ❑Neat Cement Grout entonite Chips or Pcltcts
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bcntonite Slurry ❑Other(explain under 7g)
❑Monitoring _ _ _ ❑Recovery -
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater ediation
[]Aquifer Storage and Recovery []Sal' Barrier
❑Aquifer Test Stormwater Drainage
❑Experimental Technology ❑Su dence Control
7g.Prov' a brief cription of the abando ment procedur
❑Geothermal(Closed ❑Tracer
❑Geothermal(Hearing/Cooling Return) ❑Other(ex lac rider 7g) ` ��c
Z
4.Date well(s)abandoned: U • 7' !�
J :�.fs+ t7 Lv..l�
5a.Well location:
Facilityity/�me Facility ID`#'(if applicable) S.Certifi
Phy�ssiical Address,City,and Zip z tV,/ � Signa of ertified Well.Contractor or Well Owner Date V
,� `��c) By signing this form,I hereby certify that the well(s) was (were) abandoned in
County Parccl Identification No.(PIN) accordance with 15A NCAC 02C.0100 or.2C.0200 Well Consiniction Standards
and that a copy of this record has been provided'to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.on e lat/long is sufficient) (� 9.Site diagram or additional well details:
r •7)�/ 1511
You may use the back of this page to provide additional well site details or well
N t W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS-OF-WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable.Formultiple injection or non-xatersupply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Neils: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.)
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: (fo Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
loc.For Water Supply&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) 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): (ft) abandoned.
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