Pitt_Well Abandonment_20231122

WELL ABANDONMENT RECORD FarIn,emalVaeoNLY: �
1.Well Contractor Information: WELL ABANDONMENT DETAi11S
La n a ea Q h h h 7a.For GeoprobotDPT or Closed-I.I o I Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GIV-30 is needed. Indicate TOTALNUMBER of
wells abandoned: I i
, I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining In well(s): (gaL)
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FOR WATER SUPPLY WELLS ONLY:
Company
an Name 7c.Type of disinfectant used: G�l 0
2.Well Construction Permit#:
List all applicable weft constmetion permits 0.e.U1C,County,State,Variance,eta);<f knonsr y b r
7d.Amount of disinfectant used: 1
3.Well use(check well use): I
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural [Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets ,
❑Geothermal(HeatinglCooling Supply) )6Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay °~
❑InduslriaUCornmcrcial ❑Residential Water Supply(shared) gConcrcte Grout ❑Drill Cuttings
17hsf ation ❑Specialty Grout I; ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
[Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of,mai"r is used:'
❑Aquifer Recharge ❑Groundwater Remediation b, C p n G Pe
❑Aquifer Storage and Recovery ❑Salinity1larrier I NOV 2 2, 2023
❑Aquifer Test ❑Storrowater Drainage
❑EVerimental Technology ❑Subsidence Control r,,;.;
7g.Provide a brier description of the abandonment prorledure:_,;
{]Geothermal(Closed Loop) "❑Tracer 1
❑Geothermal(Heating/Cooling Return ('❑Other(explain under 7g) -` h I O)' t1,h Q,=(M-�cut-( hf O r,I II p
.1G 3 ':Ce4�ft;a:e' •.1t�t ke c�W Gdt •I�Qc6d`, ih ? I t1J
Q.Date wells)abandoned: ;-` r
Sa.\Ne oeaHon Pei
-
La hn
rrr E(Lrl Caoh
- 'G ` off" t, .grpu�;�
Facility/Owner Name Facility ID#(if applicable) S:Certification:
iRc'� G1A.* 5W&,tg &�, l0- 13-23
Physicalr��Address,City.and Zip ����S Si' tale of Ce Well Co tractor or well Owner Date
PBy signing 1h form,!hereby certify,that the wells)was(ivete)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iftvell field,one latllong is sufficient) 9.Site diagram or additional wall'details:
You may u'se the back of this page-to provide additional well site details or well
N — \Y abandonment details. You may also attach_additional pages if necessary.—
CONSTRUCTION DETAILS OF WELL M BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attack wellcanslntclionrecord(i #74tvilable,ForniitldpletnJectlonornon-watersupplyisvlb
ONLY with the same conslntctionlabandonsent,you can submitonejonn. 10a. For All Wells: Submit this form within 30 days of completion of well
6a,Well ID#• N/A abandonment to the
following—Division of Water Resources,Information Processing Unit,
6b.Total well depth: 00 (ft.) 1617!►Tall Service Center,Raleigh,NC 276994617
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I0b.For Infection Wells: In addition to sending the form to the address in iba
6c:Borehole diameter: (fn.) above,also submit one copy of this foam within 30 days of completion of well
abandonment to the following: i
6d.\Voter level below ground surface:. (ft.) Division of Water Resources,Ui�derground Injection Control Program,
1636 A3ail,Service 6riter,,Raleigh,NC 2769971636 ,
N/t"' IG&For WaterrSiianiii&7aiectiOn,*Velisi-In°addition t6 sending the fi.-. to the.
6e.Outer casing length(if known): (ft.)
address(es)above,also submit one,cdiiy of this form within l)days of completion'
of weil.abandofinienf to-the cotinry healtli_departineot of the county where
6f.inner casing/tubing length Of!mown):�f (ft.) abandoned: G
PI
6g.Screen length Of known): I V M.)
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Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016