Craven_Well Abandonment_20230505

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Martin Glenn Cieszko 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
wells abandoned:
3 3312-A
7b.Approximate volume of water remaining in well(s):4 (gal.)
NC Well Contractor Certification Number
Cieszko Construction Company, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.)iifknown
7d.Amount of disinfectant used: oz
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout s Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Gr 1"- _ i-� lay
a Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout 1.. " Cuttings
❑Irri ation ❑ Specialty Grout MAY n 5 202F Gravel
Non-Water Supply Well: ❑ Bentonite Slurry V yul Other(explain under 7g)
❑Monitoring ❑Recovery y �f,Y {fy�0*
Injection Well: 7f.For each mate SWde amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Portland eem E 5 #
❑Aquifer Storage and Recovery ❑Salinity Barrier Pelletized Bentonite 40#
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Poured bentonite pellets into 2" PVC drop-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
leg to within 6" of the top. Capped dropleg and
4.Date well(s)abandoned: 27 April 2023 41
' steel casing to 6" above the concrete
5a.Well location: well slab with neat cement.
MCAS Cherry Point, NC N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification.-
CG, MCAS Cherry Point, NC 28533 1 May 2023
Physical Address,City,and Zip Signa r of Certifi d We ontractor or Well Ow r Date
Craven Unk
By signing this form, I hereby certify at a well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 r 1C.0200 Well Constniction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34 deg 52.803' N 76 deg 51.595' 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 well consiniction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: Unknown abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25.2 (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: 4.0 (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: 2.05 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): unknown (ft) l0c.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): 24 abandoned.
6g.Screen length(if known): unknown
(ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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