Craven_Well Abandonment_20241002 (21)

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 ofwells being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on his/her property) For nurlttple it jection or non-water supply wells ONLY with the same
corrstractiort/abutndornment,you con submit one form.
4629C
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): N/A (gal.)
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
El 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 Wen: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Benseal 6.25lbs.
13 Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stomtwater 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
,r
4.Date well(s)abandoned: 9/10/2024 O C T G 2024
5a.Well Location:
MCAS Cherry Point
Facility/Owner Name Facility ID#(if applicable) 8•
PIT 6 MCAS Cherry Point, NC, Havelock, NC 28532 September 18.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or e Oi1V� weer Date
CRAVEN By signing thisfornt I hereby cerlify that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 2C Nell 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:
You may use the back of this page to provide additional well site details or well
34.89806 N -76.88831 �p
abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For nudtiple injection or non-water supply
well ONLYwith the sane construction abandonment,you can submit one form 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: DPS-08 abandonment to the following: -
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 17.5 (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.) I Oa above,also submit one copy ofthis form within 30 days of completion
of well abandonment to the following:
6d.Water level below ground surface: 10.21.(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 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): 16.0(ft.) county where abandoned.
6g.Screen length(if known): 1.5 (ft.)
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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