Pitt_Well Abandonment_20230912

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werle
Y 7a.For Ceoprobe/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 I GW S30 is needed. Indicate TOTAL NUMBER of
3344-A wells abandoned:o^e
NC Well Contractor Certification Number 7b.Approximate volume of water!remaining in well(s): 1.04 gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS;ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable hell construction permits(i.e.WC,County,State,Variance,etc.)ifknorrn
7d.Amount of disinfectant used:I
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grog';=_ "' ri I± Dry ;lay
ir
❑Industrial/Cornmercial ❑Residential Water Supply(shared) ❑Concrete Grout o " �# mill Cuttings
❑Irrigation ❑ Specialty Grout S E P 1 12 2� Gravel
Non-Water Supply Well: ❑ Bentonite Slurry Other(explain under 7g)
RMonitoring ❑Recovery nf�o t•
Injection Well: 7f.For each material select ov ov, all-ount of materials used:
❑Aquifer Recharge ❑GroundwaterRermediation Bentonite- 25 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barier
❑Aquifer Test ❑Stomrwater Drainage Neat Cement-35 lbs. ;
[]Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑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 ID#(if applicable) 8.Certification:
East 10th Street and Parkside Drive Greenville, NC 27858
Physical Address,City,and Zip Signature of Certified I Contractor or;Well Owner Da
Pitt 5607326347
County Parcel Identification No.(PIN) By signing this•%run, 1 hereby certify that the well(s) was (were) abandoned in
ty accordance with 1 SA 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:
35.5822765 N -77.3066087 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 ivell constriction records)ifavailable. For multiple injection or non-uatersupply irells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W03 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection 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:
13.63 ft.) Division of Water Resources,Underground Injection Control Program,
(
1636 Mail Service Center,Raleigh,NC 27699-1636
NA 10c.For Water Supply&Iniection Wells: 1.addition to sending the form to the
6e.Outer casing length(if known): (ft.) address es above,also submit one co address(es) py 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 (ft.) abandoned.
I
6g.Screen length(if known): 15
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources! Revised 2-22-2016
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