Onslow_Well Abandonment_ (8)

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
2480 wells abandoned:t
7b.Approximate volume of water remaining in wells 14.35 al
NC Well Contractor Certification Number PP g (')� (gal.)
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable irell construction permils(i.e.UIC,Coanly,Stale,Variance,etc.)ifknowtt
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 Cement Gr_ . — _ ❑ Bentonite Chips or Pellets
❑Geothennal(Heating/Cooling Supply) El Residential Water Supply(single) ❑ Sand Cement Griiut<, LSi'j,Clay
❑Industrial/Commercial El Residential Water Supply(shared) ❑ Concrete Grout "� f)fih Cuttings
❑Irri ation ❑ Specialty Grout AUG 9 2022D Gravel
Non-Water Supply Well: ❑ Bentonite Slw ❑ Other(explain under 7g)
eMonitoring ❑Recovery raf_ e y uml
injection Well: 7E For each material selA1'ttig oQ'Clirovide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 16.8 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stortnwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothennal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 7-1 2-22
5a.Well location:
United States Military
Facility/Owner Name Facility ID#(ifapplicable) 8.C r ification:
Camp Lejuene, Jacksonville T , (V Z�
Physical Address,City,and Zip Si ature of Certifie ell 'ontra or or Well Owner Date
Onslow
By signing this form. I{hereby certify that the well(s) tras (here) abandoned ill
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Contraction 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.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
3838497.253 N 285722.479 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
Alloch hell convirnction record(.v)il'arailable. l•'or ntnitiple ii jeciion or non-iratersupply u•e//s
ONLY iritb Ibe same con.stirucliotr'abmulottmenl,yott can.submit one Jorut.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: GW-128 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 105 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in iOU
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: 15.3 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft•) 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): 106 (ft.) abandoned.
6g.Screen length(if known): 5 (ft.)
Fonn GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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