Craven_Well Abandonment_20241002 (10)

i
y
WELL ABANDONMENT RECORD For Internal Use ONLY:
i This form can be used for single or multiple wells -
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Trevor Mizelle 7a.Number of wells being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on his/her property) For nuduple injection or non-tvare,•supply wells ONLY with lite same
constructionlabandonment,you ea/I submit one form.
4629C
NC Well Contractor Certification Number 7b.Approximate volume;of water remaining in well(s): N/A (gala
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,Injection,etc.)ifknown 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 ❑MunicipaUPublic ❑Neat Cement Grout ®Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑IndustriaVCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation El 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 150 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test 4 Stomrwater 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 (• _- ">�.. {
4.Date wells)abandoned: 9/10/2024
ti
5a.Well Location:
MCAS Cherry Point
Facility/Owner Name Facility ID#(ifapplicable) g•Certificah� 9�
VI
PIT 6 MCAS Cherry Point, NC, Havelock, NC 28532 September 26.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CRAVEN By signing thisforin I hereby,certify that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C We/!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:
34.89793252 N -76.8884200825 �, 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
Attach well construction record(s)if available. For multiple itjection or non-water supply
well ONLYwi/h the same construction abandmnent,you can submit oneforin' 10a.For All Wells• Submit this form within 30 days of completion of well
6a.Well ID#: 100RW20 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
Ge.Borehole diameter: 4.0 (In.) 10a above,also submit one copy of this form within 30 days of completion
of well abandonment to the following:
6d.Water level below ground surface: 7.94(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): 1,5(ft.) county where abandoned.
6g.Screen length(if known):
f ..
P:\2024\224001-PIE-PS-CHERRY POINT-2ND SEM 2024 IST SEM 2025 CA.\IPIPrr 6 WELL ABANDONMENPEELD\224001_GWI'.GPJ
Adapted from 14CDENR-DIVA Form GW-30 North Carolina Department of Enviionment and Natural Resources-Division of Water Resources Revised August 2013