Pitt_Well Abandonment_20240903

WELL ABANDONMENT RECORD rorintcrtullJ_ONLY.
I. ontrsctor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DP'I'or Closed-Loop Geothermal Wells having the same
W ell Conine Name(or well owner personally abandoning,well on his her propeny) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
j/ �J wells abandoned::
NC Well Contractor Cenificatiun Number /, ,'/ /- 7b.Approximate volume of water remaining in well(s): (gal.)J111 /�(-`-1or^1 LAC[���//j��C// FOR WATER SUPPLY WELLSONLY:
Company Narne
7c.'iype of disinfectant used:
2.Well Construction Permit#:_ ___
Lut all applicable wdl comimcrian permits(i"e.UK;County,pate,Variance,etc./it Annwn
7d.Amount of disinfectant used:.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check ill that apply):
❑Agricultural ❑Alwricipal,'Public ❑ Neat Cement Grout /Bentonitc Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
0�1ndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
filirr ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Benionitc Sltury ❑Other(explain under?g I
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1l�_ 50/6 �t
❑Aquifer Storage and Recovery ❑Saltmly Barricr t
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) UTracer 7
!lGeothernal(Ileatin ,Coolin Return) (:IOthcr(explain tinder 7 ) C/
J.Date well(s)abandoned: t?'
Sa.Nell location:
Pacddy(),ncr Nawe funhty ID4(it applicable) 8.C.ertiB
Physaal,ldd, s,(ay.snit/qi ur
Signate Celli a1 Well atractor ar Well Owner Date
by signing this form, 1 hereby cerrrft that the well(s) war(were)abandoned in
t'uumy Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0100 Well Construction Standards
and that a copy oj'this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Y.f well field,one Inv long is suilkient t 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N 11 abandunmm!details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL.INSTRUCTIONS
Anachwiellcourructionrecord(i)ifotailahle. Formultipleinjecnor+ornon waiersupph eil.s
ONLY with the some twtulmt-iion/abandunnient,you can.+uhmu one liirm.
10s. For All Wells: Submit this farm within 30 days of completion of well
6a Well lD#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6h.Total well depth: /. (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter,: (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: L) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
j be.Outer casing length(if known): 10c.For Water Supply&Injectian Wells: In addition to sending the form to the
N u� (ft.)
address(es)above,also submit one copy of this farm within 30 days of completion
of well abandonment it) the county health department of the county where
6f.Inner casing/tubing length(if known): N H (ft.) abandoned.
6g.Screen length(if known): NI'I (ft.)
form GW-30 North Carolina Deparwrent of Em•vunniental Quality-Division of Watet Resotacer Re,,i,ed 2-22-2016