Craven_Well Abandonment_20241002 (40)

WELL ABANDONMENT RECORD For Internal Use ONLY:
r, y This form can be used for single or multiple Wells
1.We11,Contractor Information: WELL ABANDONMENT DETAILS
Trevor Mizelle 7a.Number of wells being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on his/her property) For nudliple itjection or non-water supply wells ONLY with the same
co siruction✓abantdonnient,your can s'ubntit one form.
4629C
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): N/A (gala
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit hl: N/A
List all applicable well permits(i.e.Connly,State,Variance,Injection,etc.)ifknown 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 ❑MunicipaVPublic ❑Neat Cement Grout ZBentonite Chips or Pellets
❑Geothermal.(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Saud Cement Grout ❑Dry Clay
❑IndustriaVCommercial ❑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: 7f.For each material selected above,provide amount of materials used:
❑Aquifer-Recharge ❑Groundwater Remediation Bentonite.Pellets 25lbs.
❑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:
❑Geothermal(Heating/Cooling Return) ❑Other(explain rider7g) Surface Pour
4.Date well(s)abandoned: 9/10/2024 n C T 1 2 2024
5a.Well Location:
MCAS Cherry Point
Facility/Owner Name FacilityIDll(if applicable) 8.Cer f tion:
PIT 6 MCAS Cherry Point, NC, Havelock, NC 28532 Seotember.l8,2024
Physical Address,City,and Zip Signature of Certified Well Contractor or We er Date
CRAVEN By signing this form I hereby certify that the ivell(s)ivas(were)abandoned in
County Parcel Identification No.(PIN) accordance ivith 15.4 NCAC 02C.0100 or 2C Rel/Construction Standards and
that a copy of this record has been provided to the hell 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:
34.8979093076 N -76.8890025565, W You may use the back ofthis.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 nutlliple ityection or non-water supply
*ell ONLY with the same construction abandonment,you can submit one form 10a.For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#: 1000W08 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 Iniection Wells: In addition to sending the form to the address in
6c.Borehole diameter: 2 (Ill.) I Oa 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: 10.30(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
6f.Inner casing/tubing length(if known): .7.7 (ft.) county where abandoned.
6g.Screen length(if known): 10(ft.)
P.\2024\224001-PIE-PS-CHERRY POINT-2ND SEM 2024_IST SEM 2025 CAMP\Prr 6 WELL ABANDONMENIiFIELD�224001_GINr.GPJ
Adapted from NCDENR-DWR Form GW-30 Nordi Carolina Department of Envvonnient and Natural Resources-Division of Water Resources Revised August 2013