Craven_Well Abandonment_20241002 (28)

WELL ABANDONMENT RECORD For Internal Use ONLY: I
• This form can be used for single or multiple wells I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Trevor Mizelle 7a.Number of wells beinlg abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on his/her property) Formalliple injection or non-wdtersupply wells ONLY with the same
cotctnvctiott/abandottment,you cart submit ate fonn.
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#: N/A
List all applicable well permits(i.e.Counly,State,Variance,Ityectiot,etc.)ifkhown 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) El Sand Cement Grout El Dry Clay
❑IndustriaUCommercial ❑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 Bentonite Pellets 175 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under7g) Surface Pour 7- 7 ^^ t
4.Date well(s)abandoned: 9/10/2024 O r T 0 G 2024
5a.Well Location:
MCAS Chem Point `1'i••.t:"�vv
Facility/Owner Name Facility ID#(ifapplicable) 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 forin I hereby cert fy that the wells)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C Rell 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:
34.8980267837 N -76.8885138215 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 if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Allach well construction record(s)ifavailable. Fa•multiple injection or not-water supply
well ONLYwith the same construction abandonment,you can subinil one forin 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well II)#: 10ORW12 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
10a above,also submit one copy of this form within 30 days of completion
6c.Borehole diameter: 4.0 (in.) ofwell abandonment to the following:
6d.Water level below ground surface: 8.58 (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 v«thin 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): 15(ft.)
P:\2024\224001-PIE-PS-CHERRY POINT-2ND SEM 2024_IST SEM 2025 CAMP\PIl-6 WELL AI3ANDONMEN9lFIELD\224001_GINT.GPJ
Adapted from NCDENR-DWR Farm GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013