WI0800219_Permit (Completion)_20241002 (3)

Department of Environmental Quality-Division of Water Resources
STATUS OF INJECTION WELL(S)/PERMIT RESCISSION REQUEST FORM
Permit Number: WI0800219 (RCRA SWMU 350—Air Injection Wells)
Permittee Name(s): MCB Camp Lejeune, Environmental Management Division,Attn: Robert Lowder
Mailing Address: 12 Post Lane
Physical Address of Well(s) (if different than mailing address):
City MCB Camp Lejeune County Onslow Zip Code 28542
Daytime Telephone No.: [phone] Cell No.:N/A
Email Address: robert.a.lowdergusmc.mil
Please check the selection which most closely describes the current status of your system:
1) ( Well(s) still used for injection activities
2) ( Well(s)not used for injection but used for other purposes: a)( Water Supply
b)( Recovery
c)( Irrigation
d)( Monitoring
3) (X)Injection discontinued and: a)( Well(s)temporarily abandoned
b)(X)Well(s)permanently abandoned
c)(X)Well(s)not abandoned
4) ( Injection well(s)never constructed ( N/A injection well(s)never proposed
Well(s)Abandonment/Comments:
If you checked(3)(a) or(b), attach a copy of the GW-30 (Well Abandonment Record). If not applicable,then describe
the method used(or to be used)to abandon the well(s), including a description of how the well were sealed and material
used. If the work below is proposed,a GW-30 will need to be submitted to the UIC Program 30 days after abandonment.
Permit Rescission:
If you checked(2),(3),or(4)and will not use a well for injection on this site in the future,you should request rescission
of the permit. Do you wish to rescind the permit?
(x) Yes ( No
Certification:
"I hereby certify,under penalty of law,which I have personally examined and am familiar with the information submitted
in this document, and that to the best of my knowledge the information is true, accurate, and complete."
LOWDER.ROBER Digitally signed by
LOW DER.ROBERT.A.1074303303
T.A.1074303303 Date:2024.09.30 09:24:35-04'00'
Signature Date
Robert Lowder Director EMD
Print or Type Name Title
GW-68 Injection Well Status Form Rev.3-1-2016 Page 1 of 1
Enclosure 2