Craven_Well Abandonment_20241002 (43)

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WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple Wells j
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Trevor MIZeIIe. . 7a.Number of wells being)abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple itycction or non-water snpply ivells ONLY with the same
constrrctim✓abandonment,you can submit one fonn.
4629C 7b.Approximate volume of water remaining in well(s): N/A (gala
NC Well Contractor Certification Number
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable well permits(i.e.County,State,Variance,hyection,etc.)iflrnoun 7d.Amount of disinfectant used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public El 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) ❑Concrete Grout El Drill Cuttings
❑Irrigation ❑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 ❑Groundwater Remediation Bentonite Pellets 175 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier.
❑AquiferTest ❑Stomlwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer .7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Surface Pour sr7­ --
4.Date well(s)abandoned: 9/10/2024 U 1, 1 0.2 2024
5a.Well Location: rt 1;
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MCAS Chem Point
Facility/Owner Name Facility ID4(if applicable) 8.Certificaa
PIT 6 MCAS Cherry-Point, NC, Havelock, NC28532 September 26,.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CRAVEN By signing thisforut I hereby certify that the ivell(s)was(Irere)abandoned in
County Parcel Identification No.(P accordance ivith 1 SA NCAC 02C.0100 or 2C 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.8980599059 N =76.8885658065 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
Aaach well construction record(s)ifavailable. For uudliple itjection or non-wager supply
well ONLYwith the same construction abandonment,you can submit oneform 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 100RW03 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in
I Oa above,also submit one copy of this form Within 30 days of completion
6c.Borehole diameter: 4.0 (In.) of well abandonment to the following:
6d.Water level below ground surface: 8.61 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A 10c.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
completion of well abandonment to the county health department of the
6f.Inner casing/tubing length(if known): -15(ft.) county where abandoned.
6g.Screen length(if known): 15(ft.)
P:\2024\224001-PIE-PS-CHERRY POINT-2ND SEM 2024_I ST SEM 2025 CAb1P\Prr 6 WELL ABANDONMENTMEM224001_GINr.GPJ
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water�Resources - Revised Aug st 2013