Pitt_Well Abandonment_20240401 (2)

WELL ABANDONMENT RECO 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 construction/depth,only 1 GWj30 is needed. Indicate TOTAL NUMBER of
2193-A -"` - wells abandoned: .
NC Well Contractor Certification Number
7b.Approximate volume of water relmaining.in well(s):" (gal.)
SG I FOR WATER SUPPLY WELLSONLY:
Company Name 2-1/2 inch hcl tabs
7c.Type of disinfectant used:
2.Well Construction Permit#t:
List all applicable well construction permits(i.e.UIC Cougv,State,Variance,etc.)ifknown '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 a Bentonite Chips or Pellets ,
❑Geothenmal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout. ❑ Dry Clay,
❑Industrial/Coininercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel, ,
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
®Monitoring. ❑Recovery -
Injection Well: - 7f.For each material selected above,provide amount of materials used:.
❑Aquifer Recharge ❑GroundwaterRemediation 6 Ibs bentonite pellets ,
❑Aquifer Storage and Recovery ❑Salinity Barrier
13AquifcrTest ❑StormwaterDrainage 2 Ibs concrete
l7Experimental Technology ❑Subsidence Control !`
7g.Provide a brief description of;the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Poured bentonite to 3 ft below toe Top 3 ft concrete.Removed manhole
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 03/20-2024
sa.Well location: >). 7 L024,
Doug Gay
Facility/Owner Name Facility ID#(if applicable) 8.Certifieatlon:
215,King George Road Greenville 27834 - 03/28/04, ;
Physical Address,City,and Zip Sign re of Certified ontractor or Well Owner Date
i
' Pitt By si nin this o-in, I hereby certi that the wells,i?as were abar`:doned in
3 S S f Y fY CI �,
County.: Parcel Identification No.(PIN) accordance with 15A NCAC 02C)01'00 or 2C.0200•Well.Coilstiuction Sidnddrds
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 IaUlong is sufficient) 9.Site diagram or additional well details:
35.'5795204 . N 77.3296035 `i 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 we!/conshvctionreco-d(s)ij'available. Forinodlipleinjectiotiot-nonu- aters+tpplywells
OA'LY ivith the sane constniction/abdndornnent,you can submit one form.
10a. For All Wells: Submit this;form within 30 'days of completion of,well
6a.Well ID#. 1 VI�y 1' abandonment to the following: . 'i•
Division of Water Resources;Information Processing'Unit;
6b.Total well depth: 19.5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 ;
t f;
10b.For Iniection Wells: In addition to sending the form to,the address'in 10a
2inch above, also submit one copy of this form within 30 days of completton,of well
6c.Borehole diameter: (in.)
abandonment to the following: ( � •, , •
fNA Division of Water Resources,`Underground Injection Control Program,,
Gd.Water level below ground surface: (t.)
1636 Mail Service Center,Raleigh,NC 276994636 ..
6e.Outer casing length(if known): NA (ft.) 10c.For Water SUUPIV&Iniection Wells: In addition to sending the forrii 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
NA abandoned t
6f Inner casm tutiin ken th >I
> g g Cf known) (ft.)
6g.Screen length(if known): NA _ (ft.)
i •
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources+ Revised 2-22-2016