Pitt_Well Abandonment_20240423 (3)

WELL ABANDONMENT RECORD For imental t)sc ONLY,
This furtn can be usedfor single.or mulliple trells:
I,welt contractor Information. WELL ABANDONMENT DETAff-i
Stefan.Smith Numhe'r of n'cps heitty("al►audgnctl:.1
WeltCotyracforKaeno(4rHsttoh"retpersor�atly phasdotdtig�xril.onliisfllsrprapcnY) Fcv'. rrurltJple tij;m8mr or rwrrltiii fer •surjrh 4i9s. ONLY anti J1,v -mkt
eorixrnroUcvum6irtafrurtuczil,lYrrr cent nrfruUt; t�zjo�ur,
3576A
Nt \Veit'Gtinlr�aorCsitificntibn.N
77b
nnsbCT ,Arpn)zimatctirimritcaf�tnhiixinaininin"�tie114aj'i ( aL)
SAEDACCO 'FOR WATER S[lPPLY WELLS ONLY;.
Coarpany Na[ns 7e,Type of disittfietatrt used:
-2:Well Construction Permit M, WM0701315,
LtV•lrlla;IpfJcvbid•uellAhvmltY�.L!Cunruj,Srrtz,furfrSrrcr,lir,'ucLpir;±ar.}orkti wt
7d:_`ttitiutit af;dLititfcet:tnt ust�l: "
3.Wcit uyr(shed:well nu):
Rater Supply Well:. .
7c;Scaling materials used(check,all'that apply):
❑A tFctdtctral. I7Mtinicili ilfi'ttblis ❑"Neat Gemcut"Grout D UcrrtonitcChips orPcllcts .
AGeothcrm3l(llcatiriG'CAvtitia$t>Frnly') ARcsidCtuitil%Vafcr.S�ttl}p1)"(sin�lcj D"Sand:Cement Grant El➢n CI;t3
t7hruiustrrrlrCnnimcrcial bRcsidcntW Watct Suppk (slmrodj ❑ConcrctcGrout. j ❑Drill tliftiup.
Olni tiaif ❑"Specially.Grutti' ❑.Grn�l
Non-lYatcrSuliph�Ve[e; ❑Hehtoaife"51ittq i • ❑Other(explainitoder7g) .
�lvlonitorbrg ❑Recowrv.
Injection Well; 7f For eaefi tuateriit sclOcd ab4i-c;provide:uriorinEof.fittffcrials ast dq
❑AquifCiRcc*,.,'c R entediutiou
❑AgttuPerStonfge01Akt cmeiy .Malinity 13lrller
Bentonite.:51b. ,wtr:gall:
❑Aquifer Test ❑Stonnt�titerDiaiquige .
❑Eairerinteutal Twhttotogy - ❑SuMidence Gantml " 7g:Frat idt s hrieF descriptian of the,allaudnnment pirictylurM.-
Meothennal(Closed Loop) " ❑Iraeer ... _..
Pour
DGeodwrtiuti fflctttin 'Caolins Retum) ®Other O. lain under? )
4,IlatcwcI1Wabandoncd: 3/12/24 I '
I • L 5u Well[Ocutian: ''_..r�+r� ;� :FA,
Speedway 8293
rlelltvi(tvocr Niumi rxillty ibm.orbppliolric) R•Cei tiltC.itl,�Ueu�e:__•II j
612 SW Greenville Blvd Greenville, NC 27858 ft
YY '•" 3/26/2024
Citr• nd Zip ` einCd Well
Physical e Ccturrrvaar fir lVefl(}iYrur D•,ue
Pitt
fljrsJ rthig lltis fo rri, !tremby,cee rpfy,4*the u•01f. Tres. uhmrdwiea'irr
4ttnut)° Parcel ldchlM=llan No.(PLN): iieci nlaiau tviflr l iA VCAC OZC.01)(J.ar 2C.4?UU.f lea i Convinkrfon SMrlihm ls"
addllrOrresopi•nfflrisi ' rt,7,rrsbE+errproviddcf16llrshellotvrren-
5h.tattitudeand longitude in degmeslminumsAccandsordccityal%del rtcco:
(tfnaa fnWi one LiOnngliAirinco) 0.Site'diagram 4add(tionalwell detail:
]'ou;iitay ttsa ttic bad}:of llii pcige:ta jirotide"additional uell site details or Avell
35.572488 77.398270 `fir Adudounteiftdetatls,You way also atiaehadditiotialpaoesifwessany
c-ciNST ucri®N nFTAIL.4(IH WELLfS$BEING ABANDONED "4LTDbtTITAi,TNS t7dt ff'T[O•FS
,tlrrrak.trrP!_eomvlrucfiva rcewetflsJ JJ'avr)lluri!tl,:''t`cv rr�rhirlr iitJrerlr�rr eu•:rwn•ireitrt su;rp!'r� "
nnNaONLY nJfh rlw airui�•"rrrrsrnarrwrlob"v,eetY,tmtrrJt_lrte eetu sirGiw'J'we�,til:Yec .1ft For All !ells:",Submit ilri_s"farm Within,3U days.of completion of tti'ell
Ga.Well 1D#•Nw-3 abandodniM to the Coilo,'hig-
Division of Water Res�o?urets,:Infor_matinu:Procrosin{;Uniti
IGl7 i�l lil Scn ice l etltcc,Relci'li,NC?7b'J9-1ti17
6U.Totat well;d►+ptlr: 18 {ft.) 1'
>lUb.E"r Inlecflon Wells: bl•addition to wading.he fount to the address In ltla
6c.:Batt:holc dlatn0ef:'1- ao,) •itrbovti,-u[so subntif otte copy of lliis l'orin it•ithiif 3U du}�s Uf cotttpteiian of till
vbundotmicat to tite foliDwing; "
TivisionorAVaterRcsuurces�'Unde round Ill ecilanControlPrti atu,
frd.Water•lcvcl b06W-groand snrfiiee. (ft;) [63G Mail Sciiicc Center,It sleigh,Ii(12;G79-IG3G
Ge.nutcr�c:ishng Icn0 h"(if known): 13 (fL) Qlc.ram\Vater;Snnnh A.iuirctlon MI19: Twaddition to scirding the form to
the addresses) abote:also submit.©ue copy of this,forul within 30 days.of
completion;of hell abandomnent to t6CL County health•deptrrrrftCJd of file County
w6cm abandoncd,
df.Inner errin;:futbinA FttittKh(if laratvn)h (ft.) j
Gg.Screen lcu);fh(If Imotrn):-5
Form M11-30 NonhCarotlru Dcporinpm ofEm-froment mid MIUMI.Ricsomces-DWislon of W'atcrAoowMs RcvEKd Aqua AL3