Pitt_Well Abandonment_20240401

WELL ABANDONMENT RECOIL For Internal Use ONLY: �
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Stuart Spruill 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 consiruction/depth,only'VGW-30 is needed. Indicate TOTAL NUMBER of
21"93-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
�+ t •
SG I FOR WATER SUPPLY WELLS'ONLY:
Company Name nfectant used: h_ 2'II2 inch hcl tabs.
7c.Type of disi
2.Well Construction Permit
List all applicable well construction permits(i.e. UIC,Comity.State,Variance,etc.)if wousr 2 1/2 inch,tabs
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 ❑Neat Cement Grout 19 Bentonite Chips or-Pellets;
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout [7 Dry Clay
Olndustria]/Commercial Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
Olrri ation ❑ Specialty Grout ❑ Gravel - -
Non-Water Supply Well. O Bentonite Slurry ❑ Other{explain under 7g)
®Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount,of materials used:
OAquifer Recharge ❑GroundwaterRemediation 6 Ibs bentonite pellet§"
l7Aquifer Storage and Recovery ❑Salinity Barrier
[:]Aquifer Test ❑StormwaterDrainage 2 Ibs concrete
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothernial(Closed Loop) OTracer
Poured bentonite to 3 ft below it Top 3 ft concrete:Removed manhole
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
03/20-2024
4.Date well(s)abandoned:
5a.Well location: •' `}'l;T
Doug Gay
4�•30 G '
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
L •
21'5 King,George Road Greenville 27834 r '{ 03/28/04
+ -Physical Address,City,and Zip ' " . Signature of Certified We " ntractor or Well Owner'-. Date
Pitt �, ;, •
By signing this form, I hereby certify that the wells)was(were) abandoned 4.
m
County _ Parcel Identification No.(PIN) accordance with ISA NCAC 02C 10100 or 2C.`0200 Wel/"Cotistntctioti"Sidndards
and that a copy of this record has been provided to the yeli owner.
5b.Latitude and longitude in degrees/minute's/seconds or decimal degrees:
(if well field,one lat/lotig is sufficient) 9.Site diagram or additional well details: .
35.5795215,` . . N 77.3296034 W You may use the back of this page io 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
ttacli well constnictioir record(s)if available.For nndtipleit jection or tion-water supply iivlls
ONLY with the sane construction/abandonment,you can submit one form. '
`A n, 10a. For All Wells: Submit this�form within 30 days.of completion.of well
M
ba.Well ID# �y 1 abandonment to the following:
Division of Water Resources,Information Processing Umt,
6b.Total well depth: 9.5 (ft.) -161.7 Mail Service Center,Raleigh,NC 27699=1627
10b.For Injection Wells: In addition to sendmg.the form to the address.•n.10a
6c.Borehole diameter:
2inch above, also submit one copy of this form within 30 days n o of completiof well
(in.)
abandonment to the following
NA' Division of Water Resources,Underground Injection Control Program,
6d.Water level below'ground surface: (ft.) 1636 Mail Service'Center,;Raleigh,NC 27699-1636
NA 10c.For Water"Suaulp&imection.Wells: In addition tt
to sending the form io the
6e.Outer casing length(if.known)- NA
address(ds)above,'also submit one copy of this form•withm.30 days of completion
of well abandonment to the county, health department of the county where"
abandoned.
6f.Inner casing/tubing length(if known): NA (ft.) ! t
6g.:Screen lengtil(if known): NA (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016