Craven_Well Abandonment_20241002 (11)

WELL ABANDONMENT RECORD For Internal Use ONLY:
i This form can be used for single or multiple wells t
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 tnultlple uyectiot+or non-water'supplythe/ls ONLY with the same
cotutruetiotdabututonmet+t,you can submit one form.
4629C 7b.Approximate volume�of water remaining in well(s): N/A (gal.)
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 welt permits ri.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 ❑Municipal/Ptlblic . ❑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 under 7g)
❑Monitoring ■Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets' 100lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stomiwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Coolin Return ❑Other(explain
( �/ g ) ( n g) Surface Pour
nrT 2024
4.Date well(s)abandoned: 9/10/2024
5a.Well Location:
MCAS Cherry Point
Facility/Owner Name Facility ID#(if applicable) 8•Certificate
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 this form 1 hereby certify that the lvell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance lvith 15ANCAC 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:
34.8979683523 768883491374 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 if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For nuultiple ijection or non-water supply
well ONLY with the same construction abandonment,you can submit ore fonn 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 1.00RW21 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
6c.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: 8.28(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 Suppiv&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):
P.\2024\224001-PIE-PS-CHERRY POINT-2ND SEM 2024 1 ST SEM 2025 CAMP\Prr 6 WELL ABAND6NMENT\FIELD\224001_GINT.GPJ
Adapted from NCDENR DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013