Pitt_Well Abandonment_20231101 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be,used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William J. Miller 7a.Number of wells being abandoned: N/A
Weil Contractor Name(or well owner personally abandoning well on his/her property). For multiple injection or non-water supply wells ONLY with fire same
cmrstrucliorvabmrdmmrent,you can submit one form. .
2927A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): N/A (gal.)
CATLIN Engineers and Scientists
FOR WATER SUPPLYIWELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#:: .N/A
List all applicable well permits(i.e.Comrry,Sta(e,_Variance,Ibjection,etc.)ifknown 7d,Amount of disinfectant used: N/A
3.Well use(check well use):
Water Supply Well: .7e:Sealing materials used(check all that apply):
•Agricultural ❑Municipal/Public ❑Neat Cement Grout 0Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential W.ater'Su 1 (single) ❑Sand Cement Grout ❑D Cla
PPY . ry Y
❑Industrial/Commercial ❑Residential Water Supply(shared)' ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under,7g)
■Monitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets —5 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) 0 Other(explainunder7g) All well materials removed and boring baekflled with
bentonite pellets.to 0.5' deep,'hydrated, then topped with
4.Date well(s)abandoned: 10/12/2023. soil ,k• a:5 a
5a.Well Location:
��ntt Y 2:0?rZ,r
Facility/Owner-Name - Facility ID#(if applicable). g•Certification:
r
3648 S. Fields Street, Farmville, NC 27828 �' October18:2023
Physical Address,City,and Zip Signature of Certified Well ntractor or Well Owner Date
PITT By signing this foini I hereby certify that the well(s).was(were)abandoned in.
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C Well Construction Standards and
that a copy of this record has been provided to the well owner.
owner.
Latitude and longitude,in degrees/minutes/seconds:or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:_
35.592725955 N =77.5997351147 .�, 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 well construction record(s)if available'For nndtiple injection or non-water supply
well ONLY with 1&same construction abandomnent,'ynu can'submit one form 10a.For All Wells.Submit this form within 30 days of completion of well
:.
6a:WeII ID#: SB03/TMW-3 , .
abandonment to.the following:
Division of Water Resources,Information Processing.Unit,
6b.Total well depth: 11.3 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the,form to the address in
109 above;also submit one copy of this form within 30 days of completion
6e.Borehole diameter: 2.(In.)- of well ban adonment to the following:
6d.Water level below ground surface: :.3.44(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail'Service Center,Raleigh,NC 27699-1636
6e.Outer casingif known): N/A 10c.For Water Sunp1Y!&'Injection Wells: In addition to sending the form
length g ( ) 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
6f.Inner casing/tubing length(if known): 1.3 (ft.) county where abandoned.
6g.Screen length(if known):
MGIN TRO]ECTSV23223_GEOSYNTEC_FARMVILLE.GM
Adapted from NCDENR DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013