Craven_Well Abandonment_20241002 (20)

WELL L BA"ONMENT RECORD For Intern aI Use ONLY:
>f +l ib This form can be used for single or multiple wells I
1.Well Contractor Information: WELL AEAND INMENT DETAILS
Trevor Mizelle 7a.Number of wells beinlg abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on his ier property) For multiple ineection or non-watersnpply welts ONLY with the sante
corutractior✓abandonment,you car submit 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 ff: N/A
List all applicable well permils(a.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/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 wider 7g)
■Monitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer•Recharge ❑Groundwater Remediation Benseal 6.25lbs.
El Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental_Technology ❑Subsidence Control
❑Geothermal(Closed Loop) El Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Surface Pour
4.Date well(s)abandoned: 9/10/2024 OCT a 2Q?A
5a.Well Location:
MCAS Cherry Point
Facility/OwnerNatne Facility IIJI#(if applicable)
8.Certification:
PIT 6 MCAS Cherry Point, NC, Havelock, NC 28532 September.l8.2024
Physical Address,City,and Zip Signature of Certified Well Coe c 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:
34.89799 N -76.88833 W You may use the back oftllis 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)ifavailable. Fornmltiple injection or non-waiersupply
well ONLYwith tliesmne construction abandauent,you can submit one fonn 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: DPS-07 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 17.6 (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: 1.0 (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: 10.13(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): 16.5 (ft.) county where abandoned.
6g.Screen length(if known):
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Adapted from NCDENR DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013