Craven_Well Abandonment_20241002 (4)

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WELL ABANDONMENT RECORD For Internal use ONLY: f
. This form can be used for single or multiple wells I
1.Well 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 luslber property) For multiple Ajection or non-watet!supply wells ONLY with the some
constnetionlabandamrent,you canlsabmil one form.
4629C
7b.Approximate volume of water remaining in well(s): N/A (gal.)
NC Well Contractor Certification Number ,
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.R'ell Construction Permit#: N/A
List all applicable_well permits(i.e.County,State,Variance,Injection,etc.)ifle nown 7d.Amount of dlSlttfCCtattt 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
OGeothermal(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: 7 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets 150 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StorrnwaterDrainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Surface.Pourp�. •z�
4.Date well(s)abandoned: 9/11/2024 O r T Q G 2024
5a.Well Location:
MCAS Chem Pointwv
Facility/Owner Name Facility ID#(ifapplicable) g•Certitica
PIT 6 MCAS Cherry Point, NC, Havelock, NC 28532 Sege tember 26.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date '
CRAVEN By signing this form I hereby certify that the ivell(s)ivas(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:
34.8981"145589 N -76.8882028869.•�, You may use the back oftlus 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
Attach well construction record(s)ifavailable. For multiple it jection or iron-water supply
Hell ONLYwilh the same consiniction abandonment,you can submit one fohi; 10a.For All Wells' Submit this form within 30 days of completion of well
6a.Well ID#:' 1.00RW09 abandonment to the.following: -
Division of Water Resources,-Information Processing Unit, "
66.Total well depth: 30 (ft.)
1617 Mail Service Center,Raleigh,NC 276994617
10b.For Iniection Wells:.In addition to sending the form to the address in
6c.Borehole diameter: .4.0 (in.) 10a 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: 8.79(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NIA 10c:For Water Supply Bc Iniection Wells: In addition to.sending the form
to the.address(es)above,also submit one copy ofthis form within 30 days of
completion of well abandonment to the county health department of the
611 Inner casing/tubing length(if known): 15(ft.) county where abandoned;
6g.Screen length(if known):
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P:\2024\224001-PIE-PS-CHERRY POINT-2ND SEM 2024_1ST SEM 2025 CAMP\PIT 6 WELL ABANDONMENIVIEL13\224001_Gwr.GPJ '
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources - Revised August 2013