Onslow_Well Abandonment_ (4)

ELL ABANDONMENT RECORD WFor Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lewis LeFever 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30�is needed. Indicate TOTAL NUMBER of
2480 wells abandoned:
7b.Approximate volume of water remaining in wells. �' 2 al.
NC Well Contractor Certification Number PP g ( )•_(gal.)
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well c•onso•uc•tion permits(i.e.t/1C,Counl,Slate,Partanc•e,etc.)ifknosra
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement out.. C�Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete GrOLII - ❑Thrill Cuttings
❑Irri ation ❑ Specialty Grout A I J G 21 J 20ZZ ❑ Gravel
Non-Water Supply Well: ElBentonite Slurry J ❑ Other(explain Linder 7g)
PlMonitoring ❑Recovery r pmrin',•�,3 Urc•,I
Injection Well: 7111 For each material seIE5tqLalJ0VK.provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation .99 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
El Aquifer Test ❑Stormwater Drainage
[]Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothennal(Closed Loop) ❑Tracer
❑Geothennal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 7-13-22
5a.Well location:
United States Military
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
Camp Lejuene, Jacksonville
Physical Address,City,and Zip Si Vature of Certified Well Con ctor or ell Owner Date
Onslow
By sighing this form, /hereby certh,that the well(s) wets (mere) abandoned ill
County Parcel Identification No.(PIN) accordance wish 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 9.Site diagram or additional well details:
3838607.673 N 285749.625 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 if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach a-ell c ottstrnc•lion record(v)i/'arailahle. 1•'or nmlliple ii yeclia»ar son-n-aler supply n•ellx
ONLY with the saute c•onsirnciian'ahanclannteni,you can s•ubnlil one ibrut.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: GW-77 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 43 (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: .75 (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: Unknown (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): (ft.) 10c.For Water Supply&Infection 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 county where
6E Inner casing/tubing length(if known): 38 (ft.) abandoned.
6g.Screen length(if known): 5 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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