Onslow_Well Abandonment_ (13)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONNIENT 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:t
7b.Approximate volume of water remaining in wells 19.11 al
NC Well Contractor Certification Number PP 1; (�)� (gal.)
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
l.i.cl all applicable well construelion pernlils(i.e.WC,County,Slam,Variance,elc.)iif'known
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.Grout, ° 1' ' .� . Bentonite Chips or Pellets
❑Geothermal(lleating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout T5 Dry Clay
❑Industrial/Commercial El Residential Water Supply(shared) ❑ ConcreteGroutp,IJ(, 2 ey 2022 ❑ Drill Cuttings
.. J
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ BentoniMYi §'_'` µ'•me Ufd Other(explain under 7g)
e Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 27.93 Gallons
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stonnwater 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: 7-12-22
5a.Well location:
United States Military
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
Camp Lejuene, Jacksonville
Physical Address,City,and Zip Sign tare of Certified Well Contr for or Well Owner Date
Onslow
By sighing this form, 1 hereby cerlij�that the ivell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Consirltction 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:
3838500.484 N 285715.429 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 irel/conslraciion record(.$)Yarailahle. l,nr Inidliple ii jeclion or aon-sratersnpply seeKv
ON/.Y frith the scone con.vn•octiott'ahmelotntnatl,yaa can sabtuii oneJornt.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: RW-14 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 19 (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: 6 (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: 6 (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&aniection 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): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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