Pitt_Well Abandonment_20240423

WELL ABANDONMENT RECORD For Internal Use ONLY:
4 ;
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Green 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 I GWf 30 is needed. Indicate TOTAL NUMBER of
4468-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of wateriremaining in well(s): 850 (gal.)
Charles R. Underwood Inc. FOR WATER SUPPLY WELLSIONLY:
Company Name 7c.Type of disinfectant used: t iTl-I
2.Well Construction Permit#:
List all applicable well construction permits(i.e.i//C,County,State,Variance,eic.)ifknoun 2.5 I Us
7d.Amount of disinfectant used: '
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural SMunicipal/Public S Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) s Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: R Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement- 2 Bags Bentonite- 60 Bags
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete Grout-45 Bags
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
Removed pump from well,confirmed total depth and static water level,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
chlorinated well, ran tremie pipe to bottom of well and grouted up,
4.Date well(s)abandoned: 4/10/24
ran tremie pipe to bottom of outer casing and grouted up, cut
5a.Well location: casings off level with floor,capped top 3ft of well with neat cement grout
Town of Winterville
Facility/Owner Name Facility lDff(ifapplicable) 8.Certification:
2418 Cannon Rd, Winterville, 28590 4/11/24
Physical Address,City,and Zip Signat of Certified Well 66ntractor 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 1 SA NCAC 02C.01 b0'or 2C.0200 Well Cot trmion Statidards) ,
and that a copy of this record has been provided to the well oitlVeC �.; .`�t are q z
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 9.Site diagram or additional well details: � q C ?
35031'56" N 77023'21" W You may use the back of this page to provide additional well sit Details or well�GZ4
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
Attach well construction record( Fan tnubiplebjectionornon-tiraiersapplyuel/s 'SUBMITTAL INSTRUCTIONS
ONLY with the same constructiomabandonmeni,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well iD#: 3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 400 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in iOa
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following: 1
6d.Water level below ground surface: 74 (ft.) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
51 (ft.) 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 county where
6f.Inner casing/tubing length(if known): (ft.) abandoned. j
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I
I'