Pitt_Well Abandonment_20240903 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY: —
1.Well Contractor Information: y, WELL ABANDONMENT DETAILS
'�&.A i -fit 1 y C ii 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Wet`con tot Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
� W 6 ( wells abandoned:
1 —
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY;
Company Name / 1
1 p� 7c Type of disinfectant used:-dA 1�.0M �61`fle
2.Well Construction Permit
List all appiicable well construction permits r.e,UIC,County,State,Variance,etc.)ifknoKrr
7d.Amount of disinfectant used: I!
3.Well use(check well use): —
Water Supply Well: 7e.Sealing materials used(check all that apply)!
❑Agicultural ❑M cipaUPublic ❑Neat Cement Grout ii li?ntoaite Chips or Pellets
❑Geothermal(lfeating/Cooling Supply) esidential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g) r
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery []Salinity Barrier --
❑Aquifer Test ❑Stormwater Drainage —,
OExperimental Technology ❑Subsidence Control
7g,Provide a brief description of the abandonment procedure:
❑Gtrothamal(Closed Loop) ❑Tracer r
❑Geothermal 11cating/Cooiing Return ❑Other(explain under 7g CiAU i'rr^j � IO�_chIQ ,�I gGe'✓1w-
LL �7 T�
�j 1L �rrnr'l�ta{�C� ��f utye(ec- �tp�ar�
4.Datewell(s)abandoned: �D
5a.Well location: (f
211 dAt-k J�rKes -
Facility/Owner Name Facility[DO if applicable) g.CertiGeatio /� J r P
(� PP i Ot
9
�t�
physical Address,City,and Zip Signature o erti Well Ctonauctor or Well Owner `Date
r By signing this form, I hereby cerr�that the welf(a)was(were)abandoned in
County Parcel Identification Na.(PIN) By
with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one la'ong is sufficient) 9.Site diagram or additional well details:
—[70 i'/ 4 �� W You may use the back of this pagr,to provide additional well site details or well
{..{ abandonment details. You may aisa attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
ONLY well con emetionrecord(s)ifavallable.For multiple injection ornon-Kvter supply wells -
ONLY with the same cowtructionlabandonment,you can submit aneform.
10a. For All Wells: Submit thi` form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: (ln.) above, also submit one copy of Ciis form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Ccnter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply At Injection Wells: ]n 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
6L Inner casing/tubing Icngth(if known): (ft-) abandoned.
6g.Screen length(if known): t`i 1:::k (ft-)
Form G W-30 North Caroline Depasanent of Unviron men tat Quality-Divisioa of Water Resources Revised 2-22-2016

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