Pitt_Well Abandonment_20231101 (6)

WELL LL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells j
1.Well Contractor Information: WELL ABANDONME&T 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-water supply wells ONLY widi the same
construction/abandonnment,you can submit one form.
2927A
NC Well Contractor Certification Number
7b.Approximate volume of water-remaining in svell(s): N/A (gal.)
-CATLIN 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 permits(i.e.County,Sta(e,Variance,hjection,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):
PAgricultural ❑Municipal/Public ❑Neat Cement Grout 0Bentonite Chips 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: ❑Benfonite Slurry ❑Other(explain under,7g)
■Monitoring, ❑Recovery
Injection Well: 7E For each material selected above,provide;amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 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/CoolirigReturn) ❑Other(explain'under 7g) All well materials removed and boring baekfilled with
bentonite pellets to 0.5' deep, hydrated, then topped with
4.Date well(s)abandoned: 10112/2023. Still
5a.Weil Location: NO .) I
Facility/Owner Name Facility ID#(if applicable) ; 8.Certification:
3648 S. Fields Street; Farmville, NC 27828 Octoberl8.2023
Physical Address,City,and Zip Signature of Certified Well ntractor or Well Owner Date
P ITT By signing this form 1 hereby certtJy that the ivell(s).was(were)abandoned in
County Parcel Identifcation No.(P" 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.'
5b:Latitude and longitude in degrees/minutes/seconds_or decimal degrees:
(if well field,one latflong is sufficient) 9.Site diagram or additional well details:
35.5931429017 N =77.5994352425. `Y 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(v)ifavailable.'For multiple injection or non-water supply
well ONLY with lhesgme construction abandomnen[,}n:rccrn"submit one form IOa.For All Wells: Submit this form within 30 days of completion of.well'
6a.Well ID#: SB06/TMW-6
abandonment to the following:
Division of Water'Resourees,Information Processing Unit,
6b.Total well depth: ' 11.3 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the.form to the address in
I Oa above;also submit one copy of this form within 30 days of completion
6c.Borehole diameter: 2-(in:): of well:abandonment to the following:.
i
'Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 3.98 (ft:)
1636 Mail-Service Center,Raleigh,NC 27699-1636
w.
6e..Outer casing length(if known): N/A 10c.For Water Supply&Infection 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
Of,Inner casing/tubing length(if known): 1.3 (ft.) county where abandoned.f: '
6g.Screen length(if known): 10 (ft.)
S:IGINTTRO]ECTS\223223_GEOSYNTEC_FARM V ILLE.GP]
Adapted from NCDENR DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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