WI0800138_Well Abandonment Record(s) (GW-30)_20200312

WELL ABANDONMENT RECORD IR01
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3561-A
1. WELL CONTRACTOR:
Nick Currie
Well Contractor (Individual) Name
Probe Technology, Inc.
Well Contractor Company Name
P O Box 1369
5. WELL DETAILS:
a.Total Depth 21 ft. Diameter: 2 in.
b. Water Level (Below Measuring Point): 7 ft.
Measuring point is 0 ft. above land surface.
6. CASING:
Street Address :
Concord, NC 28026
City or Town State Zip Code
(704 ) 933-5538
Area code Phone number 7
2. WELL INFORMATION:
SITE WELL ID # (if applicable) IR01-GW01
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)X Monitoring Residential
- Municipal/Public Industrial/Commercial Agricultural
- Recovery - Injection I- Irrigation
LL Other (list use)
3. WELL LOCATION:
COUNTY Onslow QUADRANGLE NAME
NEAREST TOWN: Jacksonville :
IR01
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
- Slope - Valley X Flat - Ridge- Other
(Check appropriate setting)
Northing 3837440.19 ' DMS OR .)CD
Easting 286656.87 DMS OR 9D
Latitude/longitude source: ®GPS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
4a. FACILITY -The name of the business where the well is located. Complete 4a ,
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY Marine Corps Air Station New River
STREET ADDRESS IR01
Jacksonville, INC
City or Town State Zip Code
8.
Length Diameter
a. Casing Depth (if known): ft.
b. Casing Removed: N/A ft.
DISINFECTION:
(Amount of 65%75% calcium hypochlorite used)
SEALING MATERIAL:
Neat Cement
Cement 27 lb.
Water 2.0 gal.
Bentonite
Bentonite lb.
Type: ❑ Slurry F Pellets
Water gal.
Other
Type material
Amount
Sand Cement
Cement lb.
Water gal.
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Grout pumped from bottom up, through tremmie pipe.
Well cover and concrete pad left in place.
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsased
11. DATE WELL ABANDONED March 6-9, 2012
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PRVIDED TO THE WELL OWNER.
Zfz
SIGNATU?FOFCERTIFIED WELL CONTRACTOR
03-20-12
DATE
Attn: Charity Rychak : SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
4b. CONTACT PERSON/WELL OWNER: (The private well owner must be an individual wbersonall�abandons his/her residential well
NAME Marine Corps Base Camp Lejeune-EMD in accordance with 15A NCAC 2C .0113.)
Nick Currie
STREET ADDRESS Bldg 12, McHugh Blvd.Jacksonville, INC
• PRINTED NAME OF PERSON ABANDONING THE WE LL
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing, Form GW-30
117 Mail Service Center, Raleigh, INC 27699-1617, Phone : [phone] Rev. 5/10

WELL ABANDONMENT RECORD IR01
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3561-A
1. WELL CONTRACTOR:
Nick Currie
Well Contractor (Individual) Name
Probe Technology, Inc.
Well Contractor Company Name
P O Box 1369
5. WELL DETAILS:
a.Total Depth 18 ft. Diameter: 2 in.
b. Water Level (Below Measuring Point): ft.
Measuring point is 0 ft. above land surface.
6. CASING:
Street Address
Concord, NC 28026
City or Town State Zip Code
(704 ) 933-5538
Area code Phone number 7
2. WELL INFORMATION:
SITE WELL ID # (if applicable) IR01-GW01R
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)X Monitoring Residential
- Municipal/Public Industrial/Commercial Agricultural
- Recovery - Injection I- Irrigation
LL Other (list use)
3. WELL LOCATION:
COUNTY Onslow QUADRANGLE NAME
NEAREST TOWN: Jacksonville
IR01
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
- Slope - Valley X Flat - Ridge- Other
(Check appropriate setting)
Northing 3837393.51 ' DMS OR .)CD
Easting 286845.23 DMS OR 9D
Latitude/longitude source: ®GPS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
4a. FACILITY -The name of the business where the well is located. Complete 4a ,
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY Marine Corps Air Station New River
STREET ADDRESS IR01
Jacksonville, INC
City or Town State Zip Code
8.
Length Diameter
a. Casing Depth (if known): ft.
b. Casing Removed: N/A ft.
DISINFECTION:
(Amount of 65%75% calcium hypochlorite used)
SEALING MATERIAL:
Neat Cement
Cement
lb.
Water
gal.
Bentonite
Bentonite
lb.
Type: ❑ Slurry F
Pellets
Water
gal.
Other
Type material
Amount
Sand Cement
Cement lb.
Water gal.
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Well not found. Previously abandoned or destroyed.
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsased
11. DATE WELL ABANDONED March 6-9, 2012
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PRVIDED TO THE WELL OWNER.
Zfz
SIGNATU?FOFCERTIFIED WELL CONTRACTOR
03-20-12
DATE
Attn: Charity Rychak : SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
4b. CONTACT PERSON/WELL OWNER: (The private well owner must be an individual wpersonall�abandons his/her residential well
NAME Marine Corps Base Camp Lejeune-EMD in accordance with 15A NCAC 2C .0113.)
Nick Currie
STREET ADDRESS Bldg 12, McHugh Blvd.Jacksonville, INC
• PRINTED NAME OF PERSON ABANDONING THE WE LL
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing, Form GW-30
1617 Mail Service Center, Raleigh, INC 27699-1617, Phone : [phone] Rev. 5/10

WELL ABANDONMENT RECORD IR01-GW02
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3287-A
1. WELL CONTRACTOR:
Terry White
Well Contractor (Individual) Name
Probe Technology, Inc.
Well Contractor Company Name
P O Box 1369
Street Address
Concord, NC 28026
City or Town State Zip Code
(704 ) 933-5538
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) IR01-GW02
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)X Monitoring Residential
- Municipal/Public Industrial/Commercial Agricultural
- Recovery - Injection I- Irrigation
LL Other (list use)
3. WELL LOCATION:
COUNTY Onslow QUADRANGLE NAME
NEAREST TOWN: Jacksonville
IR01
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
- Slope - Valley X Flat - Ridge- Other
(Check appropriate setting) :
Northing NA ' DMS OR .)CD
Easting NA DMS OR 9D
Latitude/longitude source: g]GPS (]Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
4a. FACILITY - The name of the business where the well is located. Complete 4a ,
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITYMarine Corps Base Camp Lejeune
STREET ADDRESS IR06
Jacksonville, NC
City or Town State Zip Code
4b. CONTACT PERSON/WELL OWNER: Attn: Charity Rychak
NAME Marine Corps Base Camp Lejeune-EMD
STREETADDRESSBldq 12, McHugh Blvd.Jacksonville, NC
5. WELL DETAILS:
a.Total Depth 75 ft. Diameter: 2 in.
b. Water Level (Below Measuring Point): ft.
Measuring point is ft. above land surface.
6. CASING:
Length Diameter
a. Casing Depth (if known): ft. in.
b. Casing Removed: NSA ft. in.
7. DISINFECTION:
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement 101 lb.
Water 7.5 gal.
Bentonite
Bentonite lb.
Type: ❑ Slurry F Pellets
Water gal.
Other
Type material
Amount
Sand Cement
Cement lb.
Water gal.
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Grout pumped through tremmie pipe from bottom up.
Well cover and concrete pad removed.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsased
11. DATE WELL ABANDONED September 12, 2012
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PRVIDED TO THE WELL OWNER.
10-02-12
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual wbersonall�abandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
Terry White
PRINTED NAME OF PERSON ABANDONING THE WE LL
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing, Form GW-30
117 Mail Service Center, Raleigh, NC 27699-1617, Phone : [phone] Rev. 5/10

WELL ABANDONMENT RECORD IR01
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3561-A
1. WELL CONTRACTOR:
Nick Currie
Well Contractor (Individual) Name
Probe Technology, Inc.
Well Contractor Company Name
P O Box 1369
5. WELL DETAILS:
a.Total Depth 15 ft. Diameter: 2 in.
b. Water Level (Below Measuring Point): dry ft.
Measuring point is 0 ft. above land surface.
6. CASING:
Street Address :
Concord, NC 28026
City or Town State Zip Code
(704 ) 933-5538
Area code Phone number 7
2. WELL INFORMATION:
SITE WELL ID # (if applicable) IR01-GW03
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)X Monitoring Residential
- Municipal/Public Industrial/Commercial Agricultural
- Recovery - Injection I- Irrigation
LL Other (list use)
3. WELL LOCATION:
COUNTY Onslow QUADRANGLE NAME
NEAREST TOWN: Jacksonville :
IR01
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
- Slope - Valley X Flat - Ridge- Other
(Check appropriate setting)
Northing 3837267.43 ' DMS OR .)CD
Easting 286541.04 DMS OR 9D
Latitude/longitude source: ®GPS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
4a. FACILITY -The name of the business where the well is located. Complete 4a ,
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY Marine Corps Air Station New River
STREET ADDRESS IR01
Jacksonville, INC
City or Town State Zip Code
8.
Length Diameter
a. Casing Depth (if known): ft.
b. Casing Removed: N/A ft.
DISINFECTION:
(Amount of 65%75% calcium hypochlorite used)
SEALING MATERIAL:
Neat Cement
Cement 20 lb.
Water 1.5 gal.
Bentonite
Bentonite lb.
Type: ❑ Slurry F Pellets
Water gal.
Other
Type material
Amount
Sand Cement
Cement lb.
Water gal.
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Grout pumped from bottom up, through tremmie pipe.
Well cover and concrete pad removed.
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsased
11. DATE WELL ABANDONED March 6-9, 2012
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PRVIDED TO THE WELL OWNER.
Zfz
SIGNATU?FOFCERTIFIED WELL CONTRACTOR
03-20-12
DATE
Attn: Charity Rychak : SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
4b. CONTACT PERSON/WELL OWNER: (The private well owner must be an individual wbersonall�abandons his/her residential well
NAME Marine Corps Base Camp Lejeune-EMD in accordance with 15A NCAC 2C .0113.)
Nick Currie
STREET ADDRESS Bldg 12, McHugh Blvd.Jacksonville, INC
• PRINTED NAME OF PERSON ABANDONING THE WE LL
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing, Form GW-30
117 Mail Service Center, Raleigh, INC 27699-1617, Phone : [phone] Rev. 5/10

WELL ABANDONMENT RECORD IR01
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3561-A
1. WELL CONTRACTOR:
Nick Currie
Well Contractor (Individual) Name
Probe Technology, Inc.
Well Contractor Company Name
P O Box 1369
5. WELL DETAILS:
a.Total Depth 25 ft. Diameter: 2 in.
b. Water Level (Below Measuring Point): 14 ft.
Measuring point is 0 ft. above land surface.
6. CASING:
Street Address :
Concord, NC 28026
City or Town State Zip Code
(704 ) 933-5538
Area code Phone number 7
2. WELL INFORMATION:
SITE WELL ID # (if applicable) IR01-GW07
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)X Monitoring Residential
- Municipal/Public Industrial/Commercial Agricultural
- Recovery - Injection I- Irrigation
LL Other (list use)
3. WELL LOCATION:
COUNTY Onslow QUADRANGLE NAME
NEAREST TOWN: Jacksonville :
IR01
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
- Slope - Valley X Flat - Ridge- Other
(Check appropriate setting)
Northing 3836867.42 ' DMS OR .)CD
Easting 286293.52 DMS OR 9D
Latitude/longitude source: ®GPS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
4a. FACILITY -The name of the business where the well is located. Complete 4a ,
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY Marine Corps Air Station New River
STREET ADDRESS IR01
Jacksonville, INC
City or Town State Zip Code
8.
Length Diameter
a. Casing Depth (if known): ft.
b. Casing Removed: N/A ft.
DISINFECTION:
(Amount of 65%75% calcium hypochlorite used)
SEALING MATERIAL:
Neat Cement
Cement 34 lb.
Water 2.5 gal.
Bentonite
Bentonite lb.
Type: ❑ Slurry F Pellets
Water gal.
Other
Type material
Amount
Sand Cement
Cement lb.
Water gal.
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Grout pumped from bottom up, through tremmie pipe.
Well cover and concrete pad removed.
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsased
11. DATE WELL ABANDONED March 6-9, 2012
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PRVIDED TO THE WELL OWNER.
Zfz
SIGNATU?FOFCERTIFIED WELL CONTRACTOR
03-20-12
DATE
Attn: Charity Rychak : SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
4b. CONTACT PERSON/WELL OWNER: (The private well owner must be an individual wbersonall�abandons his/her residential well
NAME Marine Corps Base Camp Lejeune-EMD in accordance with 15A NCAC 2C .0113.)
Nick Currie
STREET ADDRESS Bldg 12, McHugh Blvd.Jacksonville, INC
• PRINTED NAME OF PERSON ABANDONING THE WE LL
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing, Form GW-30
117 Mail Service Center, Raleigh, INC 27699-1617, Phone : [phone] Rev. 5/10

WELL ABANDONMENT RECORD IR01
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3561-A
1. WELL CONTRACTOR:
Nick Currie
Well Contractor (Individual) Name
Probe Technology, Inc.
Well Contractor Company Name
P O Box 1369
5. WELL DETAILS:
a.Total Depth 27.7 ft. Diameter: 2 in.
b. Water Level (Below Measuring Point): 14 ft.
Measuring point is 0 ft. above land surface.
6. CASING:
Street Address :
Concord, NC 28026
City or Town State Zip Code
(704 ) 933-5538
Area code Phone number 7
2. WELL INFORMATION:
SITE WELL ID # (if applicable) IR01-GW08
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)X Monitoring Residential
- Municipal/Public Industrial/Commercial Agricultural
- Recovery - Injection I- Irrigation
LL Other (list use)
3. WELL LOCATION:
COUNTY Onslow QUADRANGLE NAME
NEAREST TOWN: Jacksonville :
IR01
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
- Slope - Valley X Flat - Ridge- Other
(Check appropriate setting)
Northing 3837002.57 ' DMS OR .)CD
Easting 286281.43 DMS OR 9D
Latitude/longitude source: ®GPS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
4a. FACILITY -The name of the business where the well is located. Complete 4a ,
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY Marine Corps Air Station New River
STREET ADDRESS IR01
Jacksonville, INC
City or Town State Zip Code
8.
Length Diameter
a. Casing Depth (if known): ft.
b. Casing Removed: N/A ft.
DISINFECTION:
(Amount of 65%75% calcium hypochlorite used)
SEALING MATERIAL:
Neat Cement
Cement 37 lb.
Water 2.75 gal.
Bentonite
Bentonite lb.
Type: ❑ Slurry F Pellets
Water gal.
Other
Type material
Amount
Sand Cement
Cement lb.
Water gal.
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Grout pumped from bottom up, through tremmie pipe.
Well cover and concrete pad removed.
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsased
11. DATE WELL ABANDONED March 6-9, 2012
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PRVIDED TO THE WELL OWNER.
Zfz
SIGNATU?FOFCERTIFIED WELL CONTRACTOR
03-20-12
DATE
Attn: Charity Rychak : SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
4b. CONTACT PERSON/WELL OWNER: (The private well owner must be an individual wbersonall�abandons his/her residential well
NAME Marine Corps Base Camp Lejeune-EMD in accordance with 15A NCAC 2C .0113.)
Nick Currie
STREET ADDRESS Bldg 12, McHugh Blvd.Jacksonville, INC
• PRINTED NAME OF PERSON ABANDONING THE WE LL
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing, Form GW-30
117 Mail Service Center, Raleigh, INC 27699-1617, Phone : [phone] Rev. 5/10

WELL ABANDONMENT RECORD IR01
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3561-A
1. WELL CONTRACTOR:
Nick Currie
Well Contractor (Individual) Name
Probe Technology, Inc.
Well Contractor Company Name
P O Box 1369
5. WELL DETAILS:
a.Total Depth 21 ft. Diameter: 2 in.
b. Water Level (Below Measuring Point): 10 ft.
Measuring point is 0 ft. above land surface.
6. CASING:
Street Address :
Concord, NC 28026
City or Town State Zip Code
(704 ) 933-5538
Area code Phone number 7
2. WELL INFORMATION:
SITE WELL ID # (if applicable) IR01-GW09
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)X Monitoring Residential
- Municipal/Public Industrial/Commercial Agricultural
- Recovery - Injection I- Irrigation
LL Other (list use)
3. WELL LOCATION:
COUNTY Onslow QUADRANGLE NAME
NEAREST TOWN: Jacksonville :
IR01
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
- Slope - Valley X Flat - Ridge- Other
(Check appropriate setting)
Northing 3837132.55 ' DMS OR .)CD
Easting 286296.64 DMS OR 9D
Latitude/longitude source: ®GPS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
4a. FACILITY -The name of the business where the well is located. Complete 4a ,
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY Marine Corps Air Station New River
STREET ADDRESS IR01
Jacksonville, INC
City or Town State Zip Code
8.
Length Diameter
a. Casing Depth (if known): ft.
b. Casing Removed: N/A ft.
DISINFECTION:
(Amount of 65%75% calcium hypochlorite used)
SEALING MATERIAL:
Neat Cement
Cement 27 lb.
Water 2.0 gal.
Bentonite
Bentonite lb.
Type: ❑ Slurry F Pellets
Water gal.
Other
Type material
Amount
Sand Cement
Cement lb.
Water gal.
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Grout pumped from bottom up, through tremmie pipe.
Well cover and concrete pad removed.
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsased
11. DATE WELL ABANDONED March 6-9, 2012
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PRVIDED TO THE WELL OWNER.
Zfz
SIGNATU?FOFCERTIFIED WELL CONTRACTOR
03-20-12
DATE
Attn: Charity Rychak : SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
4b. CONTACT PERSON/WELL OWNER: (The private well owner must be an individual wbersonall�abandons his/her residential well
NAME Marine Corps Base Camp Lejeune-EMD in accordance with 15A NCAC 2C .0113.)
Nick Currie
STREET ADDRESS Bldg 12, McHugh Blvd.Jacksonville, INC
• PRINTED NAME OF PERSON ABANDONING THE WE LL
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing, Form GW-30
117 Mail Service Center, Raleigh, INC 27699-1617, Phone : [phone] Rev. 5/10

WELL ABANDONMENT RECORD IR01
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3561-A
1. WELL CONTRACTOR:
Nick Currie
Well Contractor (Individual) Name
Probe Technology, Inc.
Well Contractor Company Name
P O Box 1369
5. WELL DETAILS:
a.Total Depth 24 ft. Diameter: 2 in.
b. Water Level (Below Measuring Point): 12.5 ft.
Measuring point is 0 ft. above land surface.
6. CASING:
Street Address
Concord, NC 28026
City or Town State Zip Code
(704 ) 933-5538
Area code Phone number 7
2. WELL INFORMATION:
SITE WELL ID # (if applicable) IR01-GW10
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)X Monitoring Residential
- Municipal/Public Industrial/Commercial Agricultural
- Recovery - Injection I- Irrigation
LL Other (list use)
3. WELL LOCATION:
COUNTY Onslow QUADRANGLE NAME
NEAREST TOWN: Jacksonville
IR01
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
- Slope - Valley X Flat - Ridge- Other
(Check appropriate setting)
Northing 3837363.37 ' DMS OR .)CD
Easting 286474.16 DMS OR 9D
Latitude/longitude source: ®GPS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
4a. FACILITY -The name of the business where the well is located. Complete 4a ,
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY Marine Corps Air Station New River
STREET ADDRESS IR01
Jacksonville, INC
City or Town State Zip Code
8.
Length Diameter
a. Casing Depth (if known): ft.
b. Casing Removed: N/A ft.
DISINFECTION:
(Amount of 65%75% calcium hypochlorite used)
SEALING MATERIAL:
Neat Cement
Cement 34 lb.
Water 2.5 gal.
Bentonite
Bentonite lb.
Type: ❑ Slurry F Pellets
Water gal.
Other
Type material
Amount
Sand Cement
Cement lb.
Water gal.
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Grout pumped from bottom up, through tremmie pipe.
Well cover and pad left in place.
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsased
11. DATE WELL ABANDONED March 6-9, 2012
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PRVIDED TO THE WELL OWNER.
Zfz
SIGNATU?FOFCERTIFIED WELL CONTRACTOR
03-20-12
DATE
Attn: Charity Rychak : SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
4b. CONTACT PERSON/WELL OWNER: (The private well owner must be an individual wpersonall�abandons his/her residential well
NAME Marine Corps Base Camp Lejeune-EMD in accordance with 15A NCAC 2C .0113.)
Nick Currie
STREET ADDRESS Bldg 12, McHugh Blvd.Jacksonville, INC
• PRINTED NAME OF PERSON ABANDONING THE WE LL
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing, Form GW-30
1617 Mail Service Center, Raleigh, INC 27699-1617, Phone : [phone] Rev. 5/10

WELL ABANDONMENT RECORD IR01
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3561-A
1. WELL CONTRACTOR:
Nick Currie
Well Contractor (Individual) Name
Probe Technology, Inc.
Well Contractor Company Name
P O Box 1369
5. WELL DETAILS:
a.Total Depth 17 ft. Diameter: 2 in.
b. Water Level (Below Measuring Point): 5.5 ft.
Measuring point is 0 ft. above land surface.
6. CASING:
Street Address
Concord, NC 28026
City or Town State Zip Code
(704 ) 933-5538
Area code Phone number 7
2. WELL INFORMATION:
SITE WELL ID # (if applicable) IR01-GW11
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)X Monitoring Residential
- Municipal/Public Industrial/Commercial Agricultural
- Recovery - Injection I- Irrigation
LL Other (list use)
3. WELL LOCATION:
COUNTY Onslow QUADRANGLE NAME
NEAREST TOWN: Jacksonville
IR01
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
- Slope - Valley X Flat - Ridge- Other
(Check appropriate setting)
Northing 3837440.19 ' DMS OR .)CD
Easting 286685 DMS OR 9D
Latitude/longitude source: ®GPS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
4a. FACILITY -The name of the business where the well is located. Complete 4a ,
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY Marine Corps Air Station New River
STREET ADDRESS IR01
Jacksonville, INC
City or Town State Zip Code
8.
Length Diameter
a. Casing Depth (if known): ft.
b. Casing Removed: N/A ft.
DISINFECTION:
(Amount of 65%75% calcium hypochlorite used)
SEALING MATERIAL:
Neat Cement
Cement 24 lb.
Water 1.75 gal.
Bentonite
Bentonite lb.
Type: ❑ Slurry F Pellets
Water gal.
Other
Type material
Amount
Sand Cement
Cement lb.
Water gal.
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Grout pumped from bottom up, through tremmie pipe.
Well cover and pad left in place.
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsased
11. DATE WELL ABANDONED March 6-9, 2012
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PRVIDED TO THE WELL OWNER.
Zfz
SIGNATU?FOFCERTIFIED WELL CONTRACTOR
03-20-12
DATE
Attn: Charity Rychak : SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
4b. CONTACT PERSON/WELL OWNER: (The private well owner must be an individual wpersonall�abandons his/her residential well
NAME Marine Corps Base Camp Lejeune-EMD in accordance with 15A NCAC 2C .0113.)
Nick Currie
STREET ADDRESS Bldg 12, McHugh Blvd.Jacksonville, INC
• PRINTED NAME OF PERSON ABANDONING THE WE LL
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing, Form GW-30
1617 Mail Service Center, Raleigh, INC 27699-1617, Phone : [phone] Rev. 5/10

WELL ABANDONMENT RECORD IR01
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3561-A
1. WELL CONTRACTOR:
Nick Currie
Well Contractor (Individual) Name
Probe Technology, Inc.
Well Contractor Company Name
P O Box 1369
5. WELL DETAILS:
a.Total Depth 17 ft. Diameter: 2 in.
b. Water Level (Below Measuring Point): 8 ft.
Measuring point is 0 ft. above land surface.
6. CASING:
Street Address
Concord, NC 28026
City or Town State Zip Code
(704 ) 933-5538
Area code Phone number 7
2. WELL INFORMATION:
SITE WELL ID # (if applicable) IR01-GW12
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)X Monitoring Residential
- Municipal/Public Industrial/Commercial Agricultural
- Recovery - Injection I- Irrigation
LL Other (list use)
3. WELL LOCATION:
COUNTY Onslow QUADRANGLE NAME
NEAREST TOWN: Jacksonville
IR01
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
- Slope - Valley X Flat - Ridge- Other
(Check appropriate setting)
Northing 3837378.92 ' DMS OR .)CD
Easting 286821.05 DMS OR 9D
Latitude/longitude source: ®GPS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
4a. FACILITY -The name of the business where the well is located. Complete 4a ,
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY Marine Corps Air Station New River
STREET ADDRESS IR01
Jacksonville, INC
City or Town State Zip Code
8.
Length Diameter
a. Casing Depth (if known): ft.
b. Casing Removed: N/A ft.
DISINFECTION:
(Amount of 65%75% calcium hypochlorite used)
SEALING MATERIAL:
Neat Cement
Cement 24 lb.
Water 1.75 gal.
Bentonite
Bentonite lb.
Type: ❑ Slurry F Pellets
Water gal.
Other
Type material
Amount
Sand Cement
Cement lb.
Water gal.
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Grout pumped from bottom up, through tremmie pipe.
Well cover and pad left in place.
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsased
11. DATE WELL ABANDONED March 6-9, 2012
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PRVIDED TO THE WELL OWNER.
Zfz
SIGNATU?FOFCERTIFIED WELL CONTRACTOR
03-20-12
DATE
Attn: Charity Rychak : SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
4b. CONTACT PERSON/WELL OWNER: (The private well owner must be an individual wpersonall�abandons his/her residential well
NAME Marine Corps Base Camp Lejeune-EMD in accordance with 15A NCAC 2C .0113.)
Nick Currie
STREET ADDRESS Bldg 12, McHugh Blvd.Jacksonville, INC
• PRINTED NAME OF PERSON ABANDONING THE WE LL
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing, Form GW-30
1617 Mail Service Center, Raleigh, INC 27699-1617, Phone : [phone] Rev. 5/10

WELL ABANDONMENT RECORD IR01
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3561-A
1. WELL CONTRACTOR:
Nick Currie
Well Contractor (Individual) Name
Probe Technology, Inc.
Well Contractor Company Name
P O Box 1369
5. WELL DETAILS:
a.Total Depth 31 ft. Diameter: 2 in.
b. Water Level (Below Measuring Point): 20 ft.
Measuring point is 0 ft. above land surface.
6. CASING:
Street Address :
Concord, NC 28026
City or Town State Zip Code
(704 ) 933-5538
Area code Phone number 7
2. WELL INFORMATION:
SITE WELL ID # (if applicable) IR01-GW13
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)X Monitoring Residential
- Municipal/Public Industrial/Commercial Agricultural
- Recovery - Injection I- Irrigation
LL Other (list use)
3. WELL LOCATION:
COUNTY Onslow QUADRANGLE NAME
NEAREST TOWN: Jacksonville :
IR01
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
- Slope - Valley X Flat - Ridge- Other
(Check appropriate setting)
Northing 3837011.85 ' DMS OR .)CD
Easting 286992.37 DMS OR 9D
Latitude/longitude source: ®GPS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
4a. FACILITY -The name of the business where the well is located. Complete 4a ,
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY Marine Corps Air Station New River
STREET ADDRESS IR01
Jacksonville, INC
City or Town State Zip Code
8.
Length Diameter
a. Casing Depth (if known): ft.
b. Casing Removed: N/A ft.
DISINFECTION:
(Amount of 65%75% calcium hypochlorite used)
SEALING MATERIAL:
Neat Cement
Cement 41 lb.
Water 3.0 gal.
Bentonite
Bentonite lb.
Type: ❑ Slurry F Pellets
Water gal.
Other
Type material
Amount
Sand Cement
Cement lb.
Water gal.
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Grout pumped from bottom up, through tremmie pipe.
Well cover and concrete pad removed.
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsased
11. DATE WELL ABANDONED March 6-9, 2012
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PRVIDED TO THE WELL OWNER.
��fz
SIGNATU?FOFCERTIFIED WELL CONTRACTOR
03-20-12
DATE
Attn: Charity Rychak : SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
4b. CONTACT PERSON/WELL OWNER: (The private well owner must be an individual wbersonall�abandons his/her residential well
NAME Marine Corps Base Camp Lejeune-EMD in accordance with 15A NCAC 2C .0113.)
Nick Currie
STREET ADDRESS Bldg 12, McHugh Blvd.Jacksonville, NC
• PRINTED NAME OF PERSON ABANDONING THE WE LL
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing, Form GW-30
117 Mail Service Center, Raleigh, NC 27699-1617, Phone : [phone] Rev. 5/10

WELL ABANDONMENT RECORD IR01
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3561-A
1. WELL CONTRACTOR:
Nick Currie
Well Contractor (Individual) Name
Probe Technology, Inc.
Well Contractor Company Name
P O Box 1369
5. WELL DETAILS:
a.Total Depth 27.7 ft. Diameter: 2 in.
b. Water Level (Below Measuring Point): 14 ft.
Measuring point is 0 ft. above land surface.
6. CASING:
Street Address :
Concord, NC 28026
City or Town State Zip Code
(704 ) 933-5538
Area code Phone number 7
2. WELL INFORMATION:
SITE WELL ID # (if applicable) IR01-GW17
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)X Monitoring Residential
- Municipal/Public Industrial/Commercial Agricultural
- Recovery - Injection I- Irrigation
LL Other (list use)
3. WELL LOCATION:
COUNTY Onslow QUADRANGLE NAME
NEAREST TOWN: Jacksonville :
IR01
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
- Slope - Valley X Flat - Ridge- Other
(Check appropriate setting)
Northing 3837266.7 ' DMS OR .)CD
Easting 286656.87 DMS OR 9D
Latitude/longitude source: ®GPS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
4a. FACILITY -The name of the business where the well is located. Complete 4a ,
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY Marine Corps Air Station New River
STREET ADDRESS IR01
Jacksonville, INC
City or Town State Zip Code
8.
Length Diameter
a. Casing Depth (if known): ft.
b. Casing Removed: N/A ft.
DISINFECTION:
(Amount of 65%75% calcium hypochlorite used)
SEALING MATERIAL:
Neat Cement
Cement 37 lb.
Water 2.75 gal.
Bentonite
Bentonite lb.
Type: ❑ Slurry F Pellets
Water gal.
Other
Type material
Amount
Sand Cement
Cement lb.
Water gal.
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Grout pumped from bottom up, through tremmie pipe.
Well cover and concrete pad removed.
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsased
11. DATE WELL ABANDONED March 6-9, 2012
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PRVIDED TO THE WELL OWNER.
Zfz
SIGNATU?FOFCERTIFIED WELL CONTRACTOR
03-20-12
DATE
Attn: Charity Rychak : SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
4b. CONTACT PERSON/WELL OWNER: (The private well owner must be an individual wbersonall�abandons his/her residential well
NAME Marine Corps Base Camp Lejeune-EMD in accordance with 15A NCAC 2C .0113.)
Nick Currie
STREET ADDRESS Bldg 12, McHugh Blvd.Jacksonville, INC
• PRINTED NAME OF PERSON ABANDONING THE WE LL
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing, Form GW-30
117 Mail Service Center, Raleigh, INC 27699-1617, Phone : [phone] Rev. 5/10

WELL ABANDONMENT RECORD IR01
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3561-A
1. WELL CONTRACTOR:
Nick Currie
Well Contractor (Individual) Name
Probe Technology, Inc.
Well Contractor Company Name
P O Box 1369
5. WELL DETAILS:
a.Total Depth 120.6 ft. Diameter: 2 in.
b. Water Level (Below Measuring Point): 14.5 ft
Measuring point is 0 ft. above land surface.
6. CASING:
Street Address :
Concord, NC 28026
City or Town State Zip Code
(704 ) 933-5538
Area code Phone number 7
2. WELL INFORMATION:
SITE WELL ID # (if applicable) IR01-GW17DW
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)X Monitoring Residential
- Municipal/Public Industrial/Commercial Agricultural
- Recovery - Injection I- Irrigation
LL Other (list use)
3. WELL LOCATION:
COUNTY Onslow QUADRANGLE NAME
NEAREST TOWN: Jacksonville :
IR01
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
- Slope - Valley X Flat - Ridge- Other
(Check appropriate setting)
Northing 3837132.55 ' DMS OR .)CD
Easting 286296.64 DMS OR 9D
Latitude/longitude source: ®GPS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
4a. FACILITY -The name of the business where the well is located. Complete 4a ,
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY Marine Corps Air Station New River
STREET ADDRESS IR01
Jacksonville, INC
City or Town State Zip Code
8.
Length Diameter
a. Casing Depth (if known): ft.
b. Casing Removed: N/A ft.
DISINFECTION:
(Amount of 65%75% calcium hypochlorite used)
SEALING MATERIAL:
Neat Cement
Cement 162 lb.
Water 12.0 gal.
Bentonite
Bentonite lb.
Type: ❑ Slurry F Pellets
Water gal.
Other
Type material
Amount
Sand Cement
Cement lb.
Water gal.
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Grout pumped from bottom up, through tremmie pipe.
Well cover and concrete pad removed.
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsased
11. DATE WELL ABANDONED March 6-9, 2012
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PRVIDED TO THE WELL OWNER.
Zfz
SIGNATU?FOFCERTIFIED WELL CONTRACTOR
03-20-12
DATE
Attn: Charity Rychak : SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
4b. CONTACT PERSON/WELL OWNER: (The private well owner must be an individual wbersonall�abandons his/her residential well
NAME Marine Corps Base Camp Lejeune-EMD in accordance with 15A NCAC 2C .0113.)
Nick Currie
STREET ADDRESS Bldg 12, McHugh Blvd.Jacksonville, INC
• PRINTED NAME OF PERSON ABANDONING THE WE LL
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing, Form GW-30
117 Mail Service Center, Raleigh, INC 27699-1617, Phone : [phone] Rev. 5/10