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HomeMy WebLinkAboutCraven_Well Abandonment_20241002 (31) 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 Mizelle 7a.Number of wells being abandoned: N/A Well Contractor Name(or well owner personally abandoning well on his/her property) Formndtiple injection ornon-warersupply wells ONLI'wnb rile same concsrructionlabandmtntent you cant submit one form. 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.Count),State,Variance,Injection,etc.)iifthown 7d..'Amount of disinfectant used: N/A 3.Well use(checkwell 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 under 7g) ❑Monitoring ■Recovery Injection Well: 7L 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 ❑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 under 7g) SU Tace POU r �• 4.Date well(s)abandoned: 9/10/2024 0 2924 5a.Well Location: lr:�.,,. ? - •. �: _, I��, MCAS Cherry Point Facility/Owner Name Facility ID#(if applicable) 8•Certificates 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 thisform I hereby certify that the ivell(s)was(were)abandoned in County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C ffrell 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: 34.8979898373 N -76.8883001124 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 Attach well construction record(s)ifavailable. For nndtiple injection or non-water supply well ONLYtvith the same construction abandonment,you can snbmil one forts, 10a.For All Wells: Submit this form within 30 days of completion of well 6a.WeII ID#: 100RW22 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 6c.Borehole diameter: 4.0 (In.) IOa 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: 9.13 (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): 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 CAMPIPIT 6 WELL ABANDONMENT0131.13\224001_GINT.M Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division ofWater Resources Revised August 2013