Onslow_Well Abandonment_20220805

WELL ABANDONMENT RECORD For Internal Use ONLY: k
This form can be used for single or multiple wells
f ,
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Austin Fowler 7a.Number ofwells being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-waters pply wells ONLY with the same
constnrctionlahandonmem,you can submit one form.
4366A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): N/A (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)ifknmvn 7d.Amount of disinfectant,used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑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) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
■Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets 10lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
i
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Well Completely removed and hydrated bentonite pellets
I
were poured to existing qrade.
4.Date well(s)abandoned: 7/7/2022 RE _
4 M
5a.Well Location: �--
MEADOWS NA
Facility/Owner Name Facility ID#(if applicable) 8.Certification: %��G•^��"
ProceGeing UnA
CAMP LEJEUNE, NC ��ri ��"� mrm.Cr�ratit� 02
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
ONSLOW NA By signing this form I hereby certify that the well(s)hvas(were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C Well Construction Standards and
that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.583473 N -77.359793 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Allach well consirnetion records)ifavailable. For mtdliple injection or non-water supply
well ONLYwith the same construction obandonmem,you can svhmil one form 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: BB71-TW01 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in
6c.Borehole diameter: 2.25(in.) l Oa above,also submit one copy of this form within 30 days of completion
of well abandonment to the following:
'r
6d.Water level below ground surface: NM(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A 10c.For Water Supply&Iniection 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
6E Inner casing/tubing length(if known): 2 (ft.) county where abandoned.
6g.Screen length(if known): 10(ft.)
S:\GW7RPR0JEC1S\218027o2 POL LEGACEY SrrE BB71.GP1
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised Aug st 2013