Pitt_Well Abandonment_20240205

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WELL ABANDONMENT RECORD For Internal Use ONLY:
II
1.Well Contractor Information: WELL ABANDONMENT DETAILS!.
VVI Illam J. Miller •
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2927A wells abandoned: I '
7b.Approximate volume of water remaining in well(s): NIA (gal.)
NC Well Contractor Certification Number
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name N/A
7c.Type of disinfectant used: •
2.Well Construction Permit#:
List all applicable well construction pennits(i.e.UIC,County,State,Variance,etc.)if known N/A
7d.Amount of disinfectant used:_
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout I Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial' 0 Residential Water Supply(shared) ❑Concrete Grout • ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
IMonitoring ❑Recovery
Injection Well: 7f.For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets —5 lbs.
❑Aquifer Storage and Recovery i ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) All well materials removed and boring backfilled with
bentonite pellets to surface
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4.Date well(s)abandoned: 1/1 a2024
5a.Well location: A "` 'l _m
Geosyntec
Facility/Owner Name Facility ID#(if applicable) 8.Certification: yr~ FCD J 2024 •
3648 S. Fields Street, Farmville, NC 27828 Infc;� 1(29/?�024
� on r��:�.•• ..J.
Physical Address,City,and Zip Signature of Certified WA'Contractor or Well Owner V 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 2C.0200 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:
35.59339 N -77.5989 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)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: PZ-01 abandonment to the following:
84 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in I0a
6c.Borehole diameter: 4.25 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I
83
�' Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surfacer _ (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection 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 county where
6f.Inner casing/tubing length(if known): _(ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

Geosyntec Consultants Geosyntect›
Boring Log consultants
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WELL ABANDONMENT RECORD For Internal Use ONLY:
1 '
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William J. Miller 1
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2927A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): N/A (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
P y 7c.Type of disinfectant used:
2.Well Construction Permit#: '
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.)i/known
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 0 Neat Cement Grout •Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
•Monitoring ❑Recovery 1
Injection Well: 7f.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 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) All well materials removed and boring backfilled with
bentonite pellets to surface.
4.Date well(s)abandoned: 1/1 O/ZO24 --
r�•,--)
5a.Well location: '
Geosyntec F .c- ' .5 2024
Facility/Owner Name Facility IDII(if applicable) 8.Certification: ,�;'�
Yz
3648 S. Fields Street, Farmville, NC 27828 �i`��i : ^n ` K' ' `'F`
f-- ' D c G 1/29/2024 .
Physical Address,City,and Zip Signature of Certified Veil Contractor or Well Owner Date
PITT By signing this form,I hereby cert(that the well(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 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:
35.59305 N -77.599 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)iifavailable.For multiple injection or non-water supply wells
ONLY with the same construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TMW 09 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 13.99 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address.in 10a
6c.Borehole diameter:4 (in.) 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: 5.11 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): _(ft.) 10c.For Water Supply&Injection 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 county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
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6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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Geosyntec Consultants Geosyritectoe
Boring Log consultants
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Depth Time USCS!Rack Run Rae SPT J Notet Sample ID f NN:Ater
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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William J. Miller 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2927A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): N/A (gal.)
•
CATLIN Engineers and Scientists 'FOR WATER SUPPLY WELLS ONLY:
Company Name N/A '
)FM0101 3 7c.Type of disinfectant used:
2.Well Construction Permit#: I 1
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
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 a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout 0.Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout ❑Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
UMonitoring ❑Recovery
Injection Well: 7f.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 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer All well materials removed and boring backfilled with
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
bentonite pellets to surface.
4.Date well(s)abandoned: 1/10/2024
' r-.. F''"'-�
5a.Well location: - ��" % Vy r
Geosyntec 0 5 2024
Facility/Owner Name Facility RN(if applicable)
8.Certification: - ' C D
•
3648 S. Fields Street, Farmville, NC 27828 ".a -.r 'gin�; -i;� Pr:-:z...
p' 'I/29/2024
Physical Address,City,and Zip Signature of Certified W 611 Contractor or Well Owner '-'`'Date
PITT By signing this form, 1 hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 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:
35.59339 N -77.5989 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 constructionrecord(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TMW-08 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12.75 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Injection Wells: In addition to sending the form to the address in l0a
25 6c.Borehole diameter: 4- (in.) . 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 5.1 1 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection 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 county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
i l

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• Geosyntec Consultants I: Geosynte.c
Boring Log consultants
•
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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William J. Miller 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2927A wells abandoned:
N/A
NC Well Contractor Certification Number 7b.Approximate volume of water remai i ing in well(s): (gal.)
CATLI N Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name a <a r,. 7c. •
Type of disinfectant used: N/A
2.Well Construction Permit#: � '
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
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 0 Neat Cement Grout •Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation ❑Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7f.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 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer All well materials removed and boring backfilled with
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
bentonite pellets to surface.
1/10/2024 �d
4.Date well(s)abandoned:
.h rx._
5a.Well location: •
Geosyntec F r R 9076.
Facility/Owner Name Facility ID/I(if applicable) 8.Certification: n t
it:Jrn.r' Ul1'itt
3648 S. Fields Street, Farmville, NC 27828 , ' DWC4% 9/2024
Physical Address,City,and Zip Signature of CertifieciNVell Contractor or Well Owner Date
PITT By signing this form,1 hereby certibi that the wells was were abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 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 Mt/long is sufficient) 9.Site diagram or additional well details:
35.59278 N -77.5991 `,1, 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)ifavailable.For multiple injection or non-watersupplyxells
ONLY with the same constructimrabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.We11ID#: TMW707 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 13.6 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniecton Wells: In addition to sending the form to the address in 10a
4.:25 above,also submit one copy of this firm within 30 days of completion of well
6c.Borehole diameter: (in.)
abandonment to the following:
6d.Water level below ground surface: 5.2 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c..For Water Supply&Iniection 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 county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
I i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

Geosyntee Consultants Geosyntecr?
Boring Log consultants
Civiu sinicANVE9-50t0 (ZMS Boritig 'TIAN
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