Pitt_Well Abandonment_20230912 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werl ey 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/leer property) well construction/depth,only 1 GW!30 is needed. Indicate TOTAL NUMBER of
3344—A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of waterlremaining in well(s): 1.54 (gal.)
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ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if&noun
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout N Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cemen OE(^' t' ^^ ,Dry Clay
❑IndustriaVCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout >< I'� fl,Drill Cuttings
❑Irrigation ❑ Specialty Grout S E P 1 2 2023 ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
®Monitoring - ❑Recovery Ititft.rmgicn(Pr,,c Lr9
Injection Well: 7f.For each material @Igg1�dJ�ge,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite — 25 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Neat Cement�35 lbs.
❑Experimental Technology El Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Gravity feed bentonite!chips to 5' bgs
Pour neat cement from 5' bgs to ground surface
4.Date well(s)abandoned: 09/01/2023
5a.Well location:
Capital Growth Buchalter NA
Facility/Owner Name Facility IDN(if applicable) 8.Certification:
East 10th Street and Parkside Drive Greenville, NC 27858
Physical Address,City,and Zip Signature of Certified We on ctor or Well Owner Dale
Pitt 5607326347
By signing this form, I hereby ceri?&that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of•this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.58251433 N -77.30639654 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For nudtiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit oneform.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W01 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (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:
10.54 Division of Water Resources,Underground Injection Control Program,
(ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known):
NA (ft.) loc.For Water Supply&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): 5 abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resourcesi Revised 2-22-2016
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WELL ABANDONMENT RECORD For Internal Use ONLY: I,
1.Well Contractor Information: WELL ABANDONMENT DETAILS
I.
Scott M. We rl ey 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(orwell owner personally abandoning well on his/leer property) well construction/depth,only 1 GW-30'is needed. Indicate TOTAL NUMBER of
3344—A wells abandoned:On. I I
NC well Contactor Certification Number 7b.Approximate volume of water remaining in well(s): 1.05 (gal.)
ECS Southeast, LLP
FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
i
List all applicable irell construction permits(i.e.UIC,County,State,Variance,etc.)ii noun
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout -�"°—" Be c nti Chips or Pellets
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❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) El Cement Grout �'� '� D1O
❑IndustriallCommercial ❑Residential Water Supply(shared) ❑Concrete Grout IF P 11 2 "2511 Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry IrVf0;rG-0C7I Prr W1Ot6_ti_140plain under 7g)
eMonitoring ❑Recovery OWC-53OG
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Rermediation Bentonite— 25 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Neat Cement�35 lbs.
OExperimental Technology ❑Subsidence Control
7g.Provide a brief description of thelabandonment procedure:
❑Geothennal(ClosedLoop) ❑Tracer Gravity feed bentonite!ehips to 5' bgs
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Pour neat cement from 5' bgs to ground surface
4.Date well(s)abandoned: 09/01/2023
5a.Well location:
Capital Growth Buchalter NA
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
East 10th Street and Parkside Drive Greenville, NC 27858 { 5'1262
Physical Address,City,and Zip Signature ofCertified Welw,2 ctor ors Well Owner Date
Pitt 5607326347 By signing this•%rm, I hereby certify,that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0I00 or 2C.0200 Well Construction Standards
and that a copy of this record has beled provided to the well 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:
35.58236368 N -77.30685875 ,, You may use the back of this pagelto 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 nellconstruction record(s)ifavailable.For multiple injection or non-uatersupplywells
ONLY with the same construction/abandonment,you can submit one form.
IOa. For All Wells: Subunit this font within 30 days of completion of well
6a.Well ID#: MW02 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the font to the address in 10a
6c.Borehole diameter: 6 (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: 13.59 (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 font 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
6E Inner casing/tubing length(if known): 5 (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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