Pitt_Well Abandonment_20221114

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
I
Corey D. Futral 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well 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
4330-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY: §�� �„
Company Name z' - p i
7c.Type of disinfectant used: _°` i i
2.Well Construction Permit#: NA NOli
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown VV i 2O
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout 9 Bentonite Chips or Pellets vU
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
I` ❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 9 Other(explain under 7g)
GMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets —12 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage TOpS011 ^5 Ibs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Approximately 3 feet of casing removed, remainder
of well abandoned in place with hydrated bentonite
4.Date well(s)abandoned: 10/31/2022
pellets to withing 6 inches of surface and topped
sa.Well►ocation: . with topsoil to existing grade.
NCDEQ-Buck James NA
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
NC Hwy 43 and SR 1254, Falkland, 27852 11/8/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Pitt NA
By signing this form, I hereby certify that the trell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 a•2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
9.Site diagram or additional well details:
35.728187 N -77.531917 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 wellconstrucitonrecords)ifavailable.Fortnultiple injection ornon-cratersnpptvivelts
ONLY with the some consinictionlahandonment,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-5R abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 8.5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (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: 8.5 (ft-) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) loc.For Water Sunuly&Iniection 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): 3 abandoned.
6g.Screen length(if known): 5.5 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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$ MW-4R
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LEGEND : . .
-__ MW-1
® Abandoned Monitoring
Well (Type II)
Inactive Potable BUCK MO
Water Supply Well ORE RD
Approximate Location
of Former USTs
Parcel Boundary
Source:*Esri,Max arthstar,Geographics,and the1G�S`�''s'er C�ornmuniGy
NOTE:Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 50 25 0 50 100
Feet
PROJECT TITLE FIGURE
BUCK JAMES
ATLIN NC HWY 43 & SR 1254 SITE MAP
CFALKLAND, NC
Engineers and Scientists
INCIDENT NO.5233 JOB NO. 220282 GATE NOV 2022 SCALE AS SHOWN DRAWN BYICHKMC/BJA