Pitt_Well Abandonment_20231101 (4)

WELL ABANDONMENT RECO" For Internal Use ONLY:
This form can.be.used for single or multiple wells
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
William J. Miller 7a.Number of wells being abandoned: N/A
Well Contractor.Name(or well owner personally abandoning well on his/her property) For multiple injection or non-wafer supply wells ONLYwith the same
cmutnrction/abandonnfent,you can sfibnrit one form.
2927A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): N/A (gal,)
CATL iN Engineers and Scientists FOR WATER SUPPLY;WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#:' .N/A
List all applicable well pennits(i.e.Coumy,State,Variance,Injection,etc.)iiftnow» 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 ®Bentonite Clips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout .. _ ❑Dry Clay
❑Industrial/Comme.rcial ❑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: 7E For each material selected above,provide amount of materials used:
❑AquiferRecharge OGroundwaterRemediation Bentonite Pellets —5 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer.Test ❑StormwaterDrainage ...
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under7g) All well materials removed and boring baekfilled with
behtonite pellets:to 0.5' deep, hydrated, then topped with . .
4.Date well(s)abandoned: 10/12/2023 soil
5a.Well Location:
7TT tT_ L
023
8.Certification:
Facility/Owner Name Facility ID#(ifappli cable) t - _'•sue ? - -_J f ;;;'i
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3648 S. Fields Street, Farmville, NC 27828 Octoberl8,2023
Physical Address,City,and Zip Signature of.Certified Well ntractoror Well Owner Date
PITT By signing this form I hereby certify that the well(s)was(were)abandoned in .
County. Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2CWell Construction 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,one lat/long is sufficient) 9.Site diagram or additional well details:
35.5922824187 N 77.5996351267 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 well construction.record(s)if available. For multiple injection or non-water supply
well ONLY with the'same construction abandonmenl,you can submit oneforin 10a.For All Wells: Submit this form Within 30 days of completion of.-well
6a.Well ID#: SB04/TMW-4 abandonment to the following:
Division of Water Resources,Information Processing,Unit,
6b.Total well depth: 11.6 (ft.) 1617 Mai IS ervice Center,Raleigh,NC 27699-1617
10b.For Iniection 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
6c.Borehole diameter: 2 (in.) of well:abandonment to the following:
6d.Water level below ground surface:...3.37(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.:Outer casing length(if-known): N/A loc.For Water Sunaly&Iniection Wells: In addition to sending the form
to the addi•ess(es)above,,also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the
6t:Inner casin /tubin length if known): 1.5 ft. county where abandoned.
g g g (� ) ( )I
6g.Screen length(if known): 10 (ft.) ..
S:\GUVWROJECTS\223223_GEOSYNTEC FARMVILLE.GPJ
R Adapted from NCDEN DWR Form GW-30'- North Carolina Department of Environment and Natural Resources-Division of Water Resources- Revised August 2013
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