Onslow_Well Abandonment_20230828

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WELL ABANDONMENT RECORD \ Forltitemall)9 t)h1L]': ! - .
This form ran be used for single or multiple wells 3
I,Welt Contractor information: \ •••JJJ WELL ABANDONMENT DETAILS
Scott Hunt, Jr 7a.Number of wells beingubundaned: 1
WeltCoutrapor Neste(Or nett onoer Noe—finny atammtoninauclianliislberpropcny) FOr multiple oireeJon or rrrr,:rufer supple' Wells ONLY with the -sane
cn s eboniabdirdaement,)runautsu nitarefornr.'
4561-A
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NC Well ContragorCcmilk-anon Number • 7h.Apprikllmate volume of water remaining in welt(s)0 (gal.)
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used: ' •
2.Well Construction Permit It:. . • • -- • .
List all appllevbie well earns'it.Count}:Sra9e.l'unarrth.hditlian,etc)bino n 7d.Amount of disinfectant used: •
3.Well use(check well use): -
Water Supply Well: • . . 7c.Scaling inatcrials-used(cheek ill that apply): -
❑Agricultural E]Municipal/Publie ®,Nan Cenient Grunt . . 0 9cmonite Chips or Pellets .
❑ oiltermal(Ilcatin/Cooling Supply) ❑Residential Water Supply(single) 13 Sand Cement Grout O Dry Clay •
- ❑hidnstrial/Cornmerciat• ❑ResidentilWitter Supply(thited) OConcreteGrout ❑ Drill.Cuttings
- _❑irrigation ( .-.- • - . ❑Specialty Grout .❑Gravel . .
_ Non-Water Supply Well: 'C1 Bentonite Siony - ❑Other(explain under 7g)
29Monttoring• ❑Recovery
Injection Well: - . '7f.For each material selected above,provide'amoantof.materials used:
❑AqutferRecharge : ❑CrouitdoulerRentediAtion- Neat Cem.:3501b ,Wtr:20gal. Sand Cem.:lb ,Wtr:gal.
°Aquifer Storage and Recovery OSalinily Barrier -
❑Aquifer Test ❑Stomaitnter Drainage
' neat portlands Amount:
❑E.ytetirnertal Technology • ❑Subsideixe Control - 7g.Piotide a brief description of the abandonment procedure:
°Geothermal(Closed Loop) °Tracer
over drilled and removed all.pipe and- trimmy grouted from
°Geothermal(Iieating/CooiingReturn) °Other teXplainunder7g) . - -
bottom to surface
4.Dakcn'cll(s)abandoned: 7-12-23 ;. �ZL i t/tLi
Sa.Well location: AUG 2 8 2023
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MCAS Camp Lejeune '
facility/Ouvui:rN me Facility WS(liappiicablc) 8.Certitleation: loiter*�:irin Pf')G -g Un•
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4400 Douglass Rd': Jacksonville; NC 28540 549Lt. 7Vl 7/16/2023
Physical Address'.City.and Zip sigoanoeorccutmmod Well Cr' ul or•orWell(boor Date
Onslow By signing t/t_s form, 1 herby certify that the u'ell(s)was(were)abandoned in.
Canary - Parcel Identiricitlnu No:(PIN). ac valance with 1 SA AC,IC OMCC:0100.er ZC Al201)[Pell Canstr uctiun Standards
•and thin a copy of this record)tas'beetr provided(ogre well owner.
Sit.I abrade and longitude in dcgriceSlminutcslscconds or decimal degrees:
Oriel!col,onelat/}mteissuffiticrl) 9;Site diagram or additional well details:
You may use the back of this page to provide additional well site details or Well
. N W abandonment details:You may also attach additional paggs if necessary.
CONSTRIICTION.DETAIIS OFWELiIS}BEING ABANDONED StaturrFAI.INSTRUCTIONS
.intuit full constructed!:recvidfsJ if,wadable.. I of multiple bifrakpr or tin-meter supple
wege ONLY with the some eousnvrtwic aboudi xnienr.tau can submit wreAnti. 10a..Irnr_All Wells: Submit this•form within 30 day's of_completion Of well
60.Well Mg:SR93-MW-3R tibandon:tent to the following: '
Division.of WaterRrsnurcus,Information:Prucussing Unit,
14 1617 Mail Service'Center,Raleigh,NC 276994617
Gb.Total well depth: .(fr j
l(ih.E r in ieetlan_Well4: In addition to sending the form to the address in IOu
tic.Bot<hole.dianteter.2, {)ll,) above,also submit one copy of this form witllin30 days of completion of well
abandonment lathe following:
Gel.Water level below ground Surface: broken vreil (ft.) Division of Water Resource ,Underground Injection Control Program,
1636 Mail ScrticclCenter;Raleigh,NC 27699 1636
Gc Outer-easing casing ieulii(if lvr►vrn); no info (fit.) For Water Snooty&intertinn Wells: In addition to sending the fort to
the address(es) above. also submit one copy of this form within 30 days of
completion of ndl abandonment to the-county hcaith.depaitnter*of the county
no info where abandoned.
GE Inner easing/tubing length(if[nos n): OL)
6g.Screen length(If lmoss'n):no info ( )
Form GW-30 Nonb Camlhu Dcportmem oflnvirmmcnt mdi-Natural Resources-Division of WareeRomuc s Revised August 2013
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