Craven_Well Abandonment_20241002 (3)

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WELL ABANDONMENT RECORD For Internal use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Trevor MlZelle 7a.Number ofwells being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on his/her property) For nintliplo itycction or non-ivatersupply wells ONLYwith the same
constrrctionlabatidamtent,you can'ubmil one form.
4629C
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): N/A al.
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(.e.County,State,Variance,Injection,etc.)ifknoxm 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 ❑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 ❑Drill Cuttings
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under7g)
❑Monitoring ■Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets 125 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer•Test ❑Stormwater 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 pp
L 7
4.Date wells abandoned: 9/11/2024 ~
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5a.Well Location:
MCASCherryPoint
Facility/Owner Name Facility IDI/(if applicable)
8.Certificaf r DV 1'—r'
PIT 6 MCAS Cherry"Point, NC, Havelock, NC 28532 She tember 26,2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CRAVEN. By signing this form 1 hereby certify that the wells)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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:
34.8981198977 -76.8883302794 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable. For mtdliple ityection or non-water supply
well 0MYwilh the same construction abandonment,you can aubinir one form 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 100RW07 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 Infection Wells- In addition to sending the form to the address in
10a above,also submit one copy of this form within 30 days of completion
Gc.Borehole diameter: 4.0 (In.) ofwell abandonment to the following:
6d.Water level below ground surface: 8.58(ft.) Division of Water Resources,Underground Injection Control Program,.
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NIA 10c.For Water Supplv&Iniection Wells: In addition to sending the form
to the address(es)above,also submit one copy ofthis 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.)
PA20241224001-PIE-PS-CHERRY POINT-2ND SEM 2024 1ST SEM 2025 CAMPIPIT 6 WELL ABANDONNM'NT\FIELD\224001_GWT.GP7
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013