Onslow_Well Abandonment_20220620

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
D. T. Chalmers, JR. 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4146A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineer and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,Counhq State,Variance,etc)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 19 Bentonite Chips or Pellets
❑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)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets 10 Ib
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage I I I Al m, 0 &2-
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer +,- r:"•1 c'i: ::^� Lei:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pulled all well material and baekfi�ed wlF� ;�.'�,7
hydrated bentonite pellets to existing grade.
4.Date well(s)abandoned: 4/28/2022
5a.Well location:
NCDEQ-Fulp Property 00-0-0000043828 y
Facility/Owner Name Facility ID#(if applicable) S.Certification:
2225 Lejeune Blvd., Jacksonville 28546 6/16/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Onslow NA
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 2C.0200 6Vell Construction Standards
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 9.Site diagram or additional well details:
34.739611 N -77.361349 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 records)ifavailable.For multiple injection or non-water supply ivells
ONLY with,the save construction/abandonment,you can submit one,jornt.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TMW-01 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2.25 (in) 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: NM (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) 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 county where
6f.Inner casing/tubing length(if known): 5 abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

4 N
FORMER BUILDING
(DEMO'D BY OTHERS)
APPROXIMATE LOCATION
OF FORMER 4,0001GAL.
GASOLINE USTS
TMW-01
4r
APPROXIMATE LOCATIONOF
FORMER DISPENSER ISLANDS
LEGEND
Temporary Monitoring
Well (Type 1)
Approximate Location
of Former UST System
Parcel Boundary FeVo Source:Esri,Maxar,GeoEye,Earthstar Geographics,CNES/Airbus DS.
USDA,USGS,AeroGRID, IGN,and the GIS User Community
NOTE:Well installed by CATLIN on 04/28/2022.
30 15 0 30 60
Feet
FROjECT TITLE FIGURE
FULP PROPERTY
ATLIN 2225 LEJEUNE BLVD SITE MAP
CJACKSONVILLE, NC
Engineers and Scientists
INCIDENT NO JOB NO DATE SCALE DRAWS BKCRECKED BY
48144 221340 JUNE 2022 AS SHOWN KMC/BJA