Onslow_Well Abandonment_

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 1 GW-30 is needed. Indicate TOTAL NUMBER of
2480 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.50_(gal.)
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable,rem construction permits(i.e.I&.,Coanly,Stale,I'ariance,etc.)if'A»orn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling mate( als-used.{-check#11 tlta(apply):
❑Agricultural ❑Municipal/Public 9 Neat Cement G;rdttf�� `-r�.�s t.' �.,�.Bentonite Chips or Pellets
❑Geothermal(Fleating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout t f ❑ Dry Clay
❑Industrial/Commercial El Residential Water Supply(shared) ❑ Concrete Grout AIJ(' 2 21 2022 ❑ Drill Cuttings
❑Irriation ❑ Specialty Qrcltt_•, ,;fifr:vr� �K l . Gravel avel
:..r,_,�.a�.,.3 rt1
Non-Water Supply Well: ❑ Bentonite Slurry Ds Q1a-0 G ❑ Other(explain under 7g)
e Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation .76 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
El 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: 7-1 5-22
Sa.Well location:
United States Military
Facility/Owner Name Facility ID#(ifapplicable) 8.C rtificfltion:
Camp Lejuene, Jacksonville ^
Physical Address,City,and Zip Si Lure of Certified ell ontractor or Well Owner Date
Onslow
6y signing this form, /hereby cerlh,that the Ireli(s) was (rvere) abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0/00 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lit/long is sufficient) 9.Site diagram or additional well details:
3838608.344 N 285764.908 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 trell cousirnclion recard(s)ifarailable. l,itr unulliple ityec•tion orison-a,atersztpply wells
ONLY irith the saute corsvt•itclion•abondonutenl,you caa snbanil one forte.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: GW-75-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 33 (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: .75 (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: 11.3 (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 Suunly&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): 28 abandoned.
6g.Screen length(if known): 5
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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