Craven_Well Abandonment_20241002 (38)

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WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information: WELL ABANDONMENT,DETAILS
Trevor MIZelle 7a.Number of wells beinglabandoned: N/A-
Well Contractor Name(or well owner personally abandoning well on his/her property) Fa•n+etlliple injection orhon-lvatersupP/y wells ONLY with the same
.. _ constructim✓abandonment,you can submit one form. - -
4629C
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#: N/A
List all applicable Krell permits(i.e.County,State;Variance,Injection,etc.)ifRnown . 7d:Amount of disinfectant used: N/A . . . . .
3.Well use(checkwell use):
:Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic- ❑Neat Cement Grout ®Bentonite Clips or Pellets
0 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:' 7L For each material selected above,provide amount of materials used:
❑Aquifer_Recharge ❑Groundwater R.emediation Bentonite"Pellets 100lbs.
❑Aquifer Storage and Recovery ElSalinity Barrier-
❑AquifeiTest. ❑StonuwaterDrainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) []Tracer .7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain tinder 7g) Surface Pour
4.Date well(s)abandoned: 9/10/2024
5a.Well Location:
MCAS Chem Point
Facility/Owner Name Facility ID#(if applicable) g•C ertific i .
PIT 6 MCAS Cherry Point, NC, Havelock; NC28532 September.26.2024
Physical Address,City,and Zip Signature of Certified Well Contractor.or-Well Owner Date
CRAVEN.- By signing this form I hereby'certfy that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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:
34.89$0060685 N 76.888675779 You may use the back-ofthis 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)if mailable. For nndliple injection or non-water supply
well ONLYwith the same construction abandonment;you camsubmi/one form 10a.For All Wells:.Submit this form within 30 days of completion of well
6a.Well ID#: 100RW01 abandonment to the.following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (ft.)- 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Iniectiori Wells:;In addition to sending the form to the address in
I Oa above,also submit one copy of this form within 30 days of completion .
6c.Borehole diameter: 4.0 (in.) ofwell abandonment to the,following:
6d.Water level below ground surface: 8.25(ft.) Division of Water.Resources,Underground Injection.Control Program, ..
1636 Mail Service Center,Raleigh;NC 27699-1636
e 10c.For Water Supply&I Iniection Wells: In addition to sending the form
6e.0ufer casing length(if known): N/A to-the address(es)above,also'submit one copy of this form within 30 days of
completion ofwell abandonment to the county health department of.the.
6f.Inner casing/tubing length(if known): 15(ft.) county where abandoned.
6g.Screen length(if known): 15.(ft.)
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P:\2024h224001-PIE-PS-CHERRY POINT-2ND SEM 2024_1 ST SEM2025 CAMP\PIT 6 WELL A13ANDONMENr MLD\224001_GINT.GPI -
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised Aug st 2013-
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