Onslow_Well Abandonment_ (22)

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 GWT 30 is needed. Indicate TOTAL NUMBER of
2480 wells abandoned:t
NC Well Contractor Certification Number 7b.Approximate volume of waterlremaining in well(s): 0,72 (gal.)
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS'ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well c•onsiruclion permits(i.e.Ul(',County,Stale,Variance,etc.)ifkaoirn
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 a Neat Cemet���[','��,rout< — 4 )❑j Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement dyrout ❑ Dry Clay
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout A I J G D fJ ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ BentonitdiSfu7 1_"J4A*a- (�i K ;''!'•� I { (explain g)'E7t'Other ex lam under 7
s Monitoring ❑Recovery :5!'JQ':';1'0ia
injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation .99 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology [--]Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothennal(Closed Loop) ❑Tracer
❑Geothennal(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. tifieation:
Camp Lejuene, Jacksonville g -I C(- ZZ�
Physical Address,City,and Zip Si t lure of Certified Well oritractfir or Well Owner Date
Onslow
By sighing this form. I hereby certtf},that the well(s) eras (were) abandoned in
County Parcel Identification No.(PIN) accordance wilh 15A NCAC 02C.0I00 a'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 hell owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
3838600.541 N 285755.324 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
Allach hell eomslriielion rec•ord(Y)iJ'arailahle. l,im•tmd liple it jec tiar or mom-u,aler.supply wells•
ONLY with the.saute c•ott.vaztciioii cibandonntent,you can submit one fbrmt.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: GW-77 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 43 (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: (in.)
75 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: 11.75 (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&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
6E inner casing/tubing length(if known): 38 (ft.) abandoned.
6g.Screen length(if known): 5 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016