Craven_Well Abandonment_20241002 (24)

WELL ABANDONMENT RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Trevor MlZelle 7a.Number of wells being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on IiMier property). For tnuhiple injection or non-water supply wells ONLY with the same
construction✓abandonment,you can 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 ri.e.County,State,Variance,hjectiimt,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 I]Neat Cement Grout ®Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑IndustriallCommercial ❑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 ❑Groundwater Remediation Bentonite Pellets 125 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StomrwaterDrainage
❑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 well(s)abandoned: 9/11/2024
5a.Well Location: ro• ;;t
MCAS Chem Point
Facility/Owner Name Facility IDb(if applicable) g•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 I hereby certify that the ivell(s)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 hell 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:
34.8981194452 -76.8883812966 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 nuthiple injection or non-water supply
well ONLY with the same construction abandonment,you can submit one form 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 100RW06 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 Infection Wells: In addition to sending the form to the address in
6c.Borehole diameter: 4.0(In.) I Oa 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: 9.25(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh;NC 27699-1636
6c.Outer casing length(if known): N/A 10c.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 abandonment to the county health department of the
6f•Inner casing/tubing length(if known): 15(ft.) county where abandoned.
i
6'.Screen length(if known): 15(ft.)
P.W241224001-PIE-PS-CHERRY POINT-2ND SEM 2024 IST SEM 2025 CAMP\Prr 6 WELL ABANDONMENTWI]EL13\2240ol GM.GPJ
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013