Onslow_Well Abandonment_ (20)

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 constrttction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
24$0 wells abandoned:t
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.76 (gal.)
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
list all applicable well colnsavclion permits(i.e.WC,County,Stale, Variance,etc.)ifknmrn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing mat tals:a&edjchrckn►11 that-apphy):
❑Agricultural ❑Municipal/Public a Neat Cement rout—ty'a a s li.,_'L oentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Gro .t ElDry Clay
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout IJ r a " 21122 n❑ Drill Cuttings
❑Irri ation ❑ Specialty ;Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ID111110 1,31 0G ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1.23 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
❑Geothermal(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 IDN(ifapplicable) M8. r on:cati
Camp Lejuene, Jacksonville ,�2i R , ILI-zZ
Physical Address,City,and Zip SigrUure ofCertified W ontrac or or Well Owner Date
Onslow By signing this farm, /hereby cert fy that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with/SA NCAC 02C.0100 or 2C.0200 We//Construction Standards
and that a copy of this retard has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweli field,one Iadlong is sufficient) 9.Site diagram or additional well details:
3838625.344 N 285763.852 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
Anachteellconsiraciionrecord(t)ifarailahle. hbrumllipleitjeclionornon-u,alersupplyhells
ON/.Y with die scone conviruc•lion ahandonnnent,you call submit one fora.
10a. For All Wells: Submit this 1'onn within 30 days of completion of well
6a.Well ID#: GW-60 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
10b. For Infection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: 1 (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: 12.3 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.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
6f.Inner casing/tubing length(if known): 25 (ft.) abandoned.
6g.Screen length(if known): 5
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-201 G
I