Pitt_Well Abandonment_20231101 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single oc multiple wells
1.Well Contractor.Information: WELL ABANDONMENT DETAILS
.William J. Miller 7a.Number of wells beilg;abandoned•, N/A
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-watersupply wells ONLYwith the same
construction/abandonment,you can submit one form.
2927A `I
7b.Approximate volume ofwater remaining in well(s): . N/A (gala
NC Well Contractor Certification Number i
CATLIN Engineers and Scientists
FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant-used: N/A
2.W611 Construction Permit#:. .N/A
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)ifknow" 7d:'Amount of disinfectant used ' N/A
3.Well use(checkwell use):
Water Supply Well: 7e.Sealing materials-used(check all that apply):
❑Agricultural ❑MunicipaMiblic ❑Neat Cement Grout 0 Bentonite Clips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty,Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g),
EMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide.amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets —51bs.
❑Aquifer Storage and Recovery i ❑Salinity Barrier
OAquifer.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 under 7g). All well materials removed and boring backfilled with
bentonite pellets.to 0.5' deep, hydrated, then topped with
4.Date well(s)abandoned: 10/12/2023 soil
5a.Well Location:
Facility/Owner Name ,. Facility ID#(if applicable) 8•Certification:
3648 S. Fields Street; Farmville, NC 27828 %:`;4;�` = 6ctober1�8:2023
Physical Address,City,and Zip- - Signature of.Certified Well ntractor or-Well Owner Date
P rFT By signing this foi m I.hereby certify that the vvM(s).ivas(were)abandoned in.
County Parcel Identification No.(PIN) accordance.with-1 SA NCAC 02C.0100 or 2C Well 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:
35.5928459737 N -77.5994201875 �r 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 sane construction abandonment,you can submit oneform 10a.For All Wells:Submit this form within 30 days of completion of well
6a.Well ID#: $B05/TMW-5 abandonment to.the following:
Division of Water Resoui-ces,.Information Processing Unit,
6b.Total well depth: 12 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injeetion'Wells: In addition to sending the form to the address in
6c.Borehole diameter: 2 (III.) I Oa 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: 3.16 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,=NC 27699-1636
i
6e.Outer casing length(if known): N/AlOc.For Water Supply&Injection Wells: In addition to,sending the form
to the address(es)above,also submit one copy of this form withiir30 days of
completion of well abandonment to the county health department of the
6f.,Inner casing/tubing length(if known): 2-(ft.) county where abandoned.
6g.Screen length(if known): 1 0 (ft.) {
S:\GN PROJECTS\223223_GEOSYNTEC_FARMVILLE.GPJ
R Adapted from NCDEN DWR Form GW-30 North Carolina Department of Environment and Natural Resourceg-Division of Water Resources Revised August 2013