Craven_Well Abandonment_20241002 (12)

WELL ABANDONMENT RECORD For Internal Use ONLY:
B This form can be used for single or multiple wells
. 111
1.Well"Contractor Information: WELL A11ANDONMEN71i DETAILS .
Trevor MiZelle 7a.Number ofevetis being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on his/her property) For•multiple injection or non-warersupply wells ONLY with the same "
constructionlabandonment,you can submit one form. '
4629C IJ
NC Well Contractor Certification Number 7b.Approximate volume ofwater 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#: .2869 "
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)ifknown 7d.AmOnnt 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 El Di Clay,
❑Industrial/Commercial ❑Residential Water Supply(shared) []Concrete Grout ❑Drill Cuttings" ,
❑Irrigation O Specialty Grout El Gravel
Non-Water Supply Well: :.. ❑Bentonite"Slurry ❑Other(explain under 7g)
■Monitoring. ❑Recovery'
Injection Well: .7t For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite"Pellets 25lbs.
-Aquifer Storage and Recovery ❑Salinity Barrier,
❑Aquifei'Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed-Loop) ❑Tracer" 7g.Provide a brief description of the abandoument:procedure: "
❑Geothermal(Heating/Cooling Return)' ❑Other(explain under 7g) Surface Pour
C.
.. 4.Date wells abandoned: 9/11/2024 "
O C T�0 2 2024
5a.Well Location:
MCAS Cherry Point _ DIN'.' tee t__
Facility/Owner Name Facility ID#(if applicable) 'C/P _
8 ti
PIT 6 MCAS Cherry Point, NC, Havelock,.NC 28532 September 18.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or We er Date
CRAVEN' By signing thisfonn I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with•15A NCAC 02C.0100 or 2C Well.Consiruction Standards and '
thara:copy of this record has been provided to the well owner.:
'51i: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:
34.8978591505 Nr 76.8881558086: 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 well construction record(s)ifavailable. For multiple itjection or non-water supply
well ONLYwith the same construction abandonment,you can sgbrriit oiue form 10a.For All Wells-.Submit:this form within-30 days of completion of well:'. -
6a.Well ID#: 1000W03 -abandonment to the following:
Division of Water Resources,Information Processing Unit,.
6b.Total well depth: 18 .(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Iniectiori Wells:.'1n addition to sending the form to the address in "
10a above,also submit one•copy of this form within 30 days of completion
6c.-Borehole diameter: -2 (In.) of well abandonment to the following: -
6d.Water"level below ground surface: 9.00 (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&4niection 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
6f.Inner casing/tubing length(if known): 8 (ft.) county where abandoned.
-6g.Screen length(if known): • 10(ft.)
P:\2024M4001-PIE-PS-CHERRY POINT-2ND SEM 2024_IST SEM'2025 CAMP\Prr 6 WELL ABANDONMENT\FIELD\224001_Gwr.GPJ
Adapted from NCDENR DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources "• _ Revised Aug st 2013