Onslow_Well Abandonment_ (17)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lewis LeFever 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
wells abandoned:t
2480
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2.77 (gal.)
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UlC,County,Slate,Variance,etc.)ifknowu
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 e Neat Cement irout r : -; ja^ entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout AUG 9- .i 2022 ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Si�ift�++' '=� ' '` lt!Mther(explain under 7g)
eMonitoring ❑Recovery 11_;WQ1:110C"
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 5.12 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 7-13-22
5a.Well location:
United States Military
Facility/Owner Name Facility ID#(ifapplicable) 8.C tification:
Camp Lejuene, Jacksonville q. ZZ
Physical Address,City,and Zip Sig ture of Certified Wel ontra for or Well Owner Date
Onslow
By signing this form, 1 hereby certify that the ivell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one latilong is sufficient) 9.Site diagram or additional well details:
3838553.4 N 285684.967 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
Auac•h well c•onstruciion rec•nrd(s)tl'available. Pbr muhiple ityection or non-water supply wells
ONLY with the same c•onsiruction%abandona,eni,you can submit one jbrn,.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: GW-52R abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 32 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (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: 14.7 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 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 county where
611 Inner casing/tubing length(if known): 27 (ft.) abandoned.
6g.Screen length(if known): 5 (ft.)
Form GW-30 North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 2-22-2016
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