WI0800330_Well Construction Record(s) (GW-1)_20130426

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
William Miller 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 6 ft 15 ft Black very fine dense sands
2927-A ft. I ft-
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists ft. ft in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
W 10800330 FROM TO DIAMETER THICKNESS MATERLAL
2.Well Construction Permit#: ft ft in.
List all applicable well construction permits(i.e.County,State.Variance,etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 4 ft. 2 ft.
Non-Water Supply Well:
ft ft
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothenmal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soit/mck type, rain sae,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft 4 ft Tan sandy clay-compacted
4.Date Well(s)Completed: Well ID# g
11-17-2013 IP1 through IP9 4 ft 13 ft Dark colored very fine to fine dense sands
13 f` 15 f`• Black very fine flowing sands
5a.Well Location: ft. ft
MCB Camp Lejeune ft ft.
Facility/Owner Name Facility ID#(if applicable) ft ft.
12 Post Lane, Camp Lejeune, NC 28547 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Onslow
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one IaD7ong is sufficient)
34 44 21.77 N -77 27 25.74 W ..elm;i� �3
ignatur f Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or IOTemporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under-21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 9 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construcdon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 15 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf dt(ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 6 BGL (ft.) Division of Water Quality,Information Processing Unit,
lfwater level is above casing,use-1- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4.75 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Hollow Stem Auger above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
139.Yield(gpm) Method of test: 24c.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
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of W ater Quality Revised Jan.2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Miller 7a.Number of wells being abandoned: 9
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY a ah the c w
construeiion'abandomnent,you can submit one farm.
2927-A 9 Wells =18
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: W 10800330
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) O Concrete Grout ❑Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge OGroundwaterRemediation 0.48 cu. ft. Concrete Grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Placed mixed concrete onto packed ORC pellet and sand mixture.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 4-1 8-2013
5a.Well location:
Camp Lejeune
Facility/O«nerName Facility ID#(ifapplicable) 8•CertiLeatioo:
12 Post Lane, Camp Lejeune, NC 28547 ��� ��-��� ¢2(o-13
Physical Address,City,and Zip Signature aKertified Well Contractor or Well Owner Date
OnSIOW By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I SA NCAC 02C.0100 or 2C.0200 Well Construction 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:
(ifwell field,one latflong is sufficient) 9.Site diagram or additional well details:
34 44 21.77 -77 27 25.74 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 pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same constructioniabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: I P 1 to I P9 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: (ft)
15 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
4.75 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter. (in.) abandonment to the following:
6d.Water level below ground surface: 6 Division of Water Quality,Underground Injection Control Program,
(ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NSA I0c.For Water Supply &Injectiom Wells: In addition to sending the form to
(ft.) 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
6f.Inner casing/tubing length(if known): N/A (ft.) where abandoned.
6g.Screen length(if known): N/A (ft)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013