Craven_Well Abandonment_20241002 (22)

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WELL ABANDONMENT RECORD For Internal Use ONLY:
(. This form can be used for single or multiple wells I i
L Well Contractor Information: - WELL ABANDONMENT DETAILS
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Trevor Mizelle 7a.Number ofwells beingtabandoned: N/A
Well Contractor Name(or well owner personally abandoning well on hillier property) For nndriple injechm,or„a,-warersupply wells ONLY with the same
co,utrncho,✓abar,donnrent,yo,r can submit one form.
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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 well permits(i.e.County,State,Variance,Ljecrion,etc.)it'known 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.
❑IndustriaUCominercial ❑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:. 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonitee-Pellets 25lbs.
❑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/Coolilig Return) ❑Other(explain under 7g) Surface Pour '' F— T'
•.-r A 'Y
4.Date well(s)abandoned: 9/10/2024 G
5a.Well Location:
MCAS Chem Point .• 4
Facility/Owner Name Facility ID (if applicable) 8•Cc
rt
PIT 6 MCAS Cherry-Point, NC, Havelock, NC 28532 September 18,2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Mer Date
CRAVEN By signing this form I hereby certify that the lvell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance Ivith 1 SA NCAC 02C.0100 or 2C Well,Constnrction Standards and
that a copy of this record has been provided to the it-ell 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:
34.8980398958 Nr =76.8884998393 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well consiniction record(s)ifavailable. For mahiple hyection or non-water sapply
well ONLYwith the same construction abandonment,you cansnbmil one jonn 10a.For All Wells: Submit this form within'30 days of completion of well
6a.Well ID((: 10OGW01 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 .(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniectiou Wells:In addition to sending the form to the address in
6c.Borehole diameter: 2.(in.) 10a above,also submit one copy of this form within 30 days of completion
of well abandonment to the following:
Q.Water level below ground surface: 9.81 (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 't, loc.For Water Supply&Injection 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 abandomuent to the county health department of the
6f.Inner casing/tubing length(if known): 5(ft.) county where abandoned.
fig.Screen length(if known): 15(ft.)
P_\2024M4001-PIE-PS-CHERRY POINT-2ND SEM 2024 1ST SEM 2025�CAMP\Prr 6 WELL ABANDONMENTTIELD\224001_MT.GP7 ..
Adapted from NCDPNR-DWR Form OW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources - Revised Auo st 2013