Onslow_Well Abandonment_20241025 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY
This form can be used for single or multiple wells
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 his/her property) For multiple uyection or non-water supply wells ONLI with the same
construction abumlonment,you can.submit one form.
4629C
NC Well Contractor Certification Number 7b.Approximate volume of water 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 well permits(i a County,State,Vaita-e Injection,etc.){jknown 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 ❑Municipal/Public ❑Neat Cement Groo , l ! . 0Ben oirjte Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout d Drytray
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout O r T 2 �� 2O Wrill Cuttings
❑Irrigation ❑Specialty Grout O Gravel
Non-Water Supply Nell: ❑Bentonite Slurr)r,`5..'p.i' . P-r^ar,09t0paxplain under 7g)
■Monitoring ❑Recovery -r
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets —51bS.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7,,. Prot file a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) All well materials removed and boring backfilled with
bentonite to ground surface.
4.Date well(s)abandoned: 9/19/2024
5a.Well Location:
MCB Camp Leieune
Facility/Owner Name Facility m#(if applicable) 8.(ertification: /;4Ll9Z
Onslow County,NC 28540,Jacksonville,NC 28540 September 26.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner i):n':
O N S L O W By signing this form 1 hereby certift that the well(s)was(were)abandoned in
Count} 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:
34.64401 -77.402701 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach weli consirac•tion record(s)tjavailable. For mulitple iryectton or non-water suppl v
well ONLYwith the same construction abandonment.you can submit one form 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TMW-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection 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: 1.0(in.) of well abandonment to the following:
6d.Water level below ground surface: 2.23(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&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
6f.Inner casing/tubing length(if known): 5(ft.) county where abandoned.
6g.Screen length(if known): 10(ft.)
P\2023\223149 DAVENPORT-EMERGENCY RESPONSE\223149.02-511 LIFT STATION\WELL CON PACKAGE•\223149.02_GNR_5I I LIFT STATION.GPI
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013