Pitt_Well Abandonment_20240731

,WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
John Salmon 7a.For GcoprobdDPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well cons tructionidepth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
3497-A wells abandoned: _
NC Well Contractor Certification Number 7b.Approximate volume of ivater remaining in well(s): 10 (gal.)
Applied Resource Management FOR WATER SUPPLY WELLS ONLY:
Company Name HtH
2.Well Construction Permit#:
PWS2024-100827 7c.Type of disinfectant used:
List all applicable Hell conrteuction permils(t.e.UIC.County,State,irariance,etc.)tfbtown 1 lb.
7d.Amount of disinfectant used: _
3.Well use(check well use);
Water Supply Well: 7e.Sealing materials used(check al that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentoaite Chips or Pellets
❑Geothermal(Hewing/Cooling Supply) IllResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑IndustrialfCommercial ❑Residential Water Supply(shared) N Concrete Grout ❑Drill Cuttings
❑Uri ation 9 Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring Recovery
Injection Well: _ � 717.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 15 Bags DF grout
❑Aquifer Storage and Recovery '' ' .� ❑Salinity Barrier �—
[yhC•i
❑Aquifer T 20 Gallons of 3001b. concrete
est ❑Stormwater Drainage
OExperimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geathennal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) ❑Other(explainunder7 ) Drilled casing out with 1i3 1/4 bit, hit concrete at 78'.
Cleaned hole and set irEimie pipe in at 18'. Pumped
a.Date rvell(s)abandoned: 4/24/2024 15 bags of DF grout, 430 gallons total. Capped well
52.Well location: off with 2' 3001b.,concrete.
Acadia-Vidant Joint Venture LLC
Facility/Owner Name Facility IDN(if applicable) 8.Certification:
2820 MacGregor Downs Road, Greenville 27834
& 4/24I2024
Physical Address,City,and Zip Signatu fCenified Well Comractor or Well Owner Date
Pitt 89880
By signing this form, I hereby certify that the ivell(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.6100 or 2C.0200 Nell Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of This record hus been provided to the well owner.
(ifwell field,one Iat/long is sufficient) 9.Site diagram or additional weR details:
35 136'-frr3.553" N 77 255' 1 n.83o �Y You may use the back of this page to provide additional well site details or well
abandonment details. You may also at:aeh additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEiNG ABANDONED SUBMITTAL INSTRUCTIONS
dltarhHcllrunslructianrecurd(s)�availabla For muhiple injection ornon-r.ntersupplywells
O,VLY rvi/b tl)e sane conctructionlabandonment,you can submit oneform.
1Da. For All Wells: Submit this form within 30 days of completion of well
62.Well iD#: abandonment to the following:
Divlslon of Water Resources,Information Processing Unit,
6b.Total well depth: 18 1617 mall Service Center,Raleigh,NC 27699-1617
1015,For Infection Wells: In addition to sending the romi to die address in 10a
6c.Borehole diameter: 24 (in,) above, also submit one copy of this form within 30 days or completion of well
abandonment to the following:
6d.Water level below ground surface: 6 (ft) Division of Water Resources,Underground Infection Control Program,
1636 hall Service Center,Ralcigh,NC 27699-1636
6e.Outer casing length(if knowu): 18 10c.For Water Supply&rniection Wells; In addition to sending the form to die
address(es)above,also submit one aopy of this form within 30 days of completion
of well abandonment to'the county health department of the county where
6L Inner casing/tubing length(if known): N/A (ft.) abandoned.
6g.Scrcen length(if known): NIA (ft.)
Fomi GIV-30 North Carolina Department of Fnvironincntal Quality-Division of water Resources Revised 2-22-2016