Craven_Well Abandonment_20241002 (32)

WELL ABANDONMENT RECORD For Internal Use ONLY:
4 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 Nanle(or well owner personally abandoning well on his/her property) For multiple injection a•non-watersupply wells ONLY with the same
consinretionlabandonment,you can submit one fornt.
4'629C '
NC Well Contractor Certification Number
7b.Approximate volumel,oI ;f 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)ifknou'n 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 ❑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: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Benseal 6.25lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stomlwater 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
4.Date well(s)abandoned: 9/10/2024
5a.Well Location:
MCAS Cherry Point "
Facility/Owner Name Facility ID#(if applicable)
8.C rt•nation• `C'4° •:,4�;t•tr
PIT 6 MCAS Cherry Point, NC, Havelock, NC 28532 September 18.2024
Physical Address,City,and Zip Signature of Certified Wet.Contractor or 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 I5A NCAC 02C.0100 or 2C Well Construction Standards and
that a copy ofthis 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:
34.89797 N 76.88847 W You may use the back ofthis page to provide additional well site details or well .
abandonment details.'You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. Formultiple injection or non-wafer supply
vi,ell ONLYspill;the same construction abandonment,you can subunit onefonn 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: DPS-04 abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth: 16.5 (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.) 1 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: 10.01 (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 loc.For Water Supply&Iniection Wells: In addition to sending the form
to the address(es)above,also submit one copy ofthis form within 30 days of
completion of well abandomnent to the county health department of the
6f.Inner casing/tubing length(if known): 15.5 (ft.) county where abandoned.
6g.Screen length(if known):
P.\2024\224001-PIE-PS-CHERRY POINT-2ND SEM 2024_1ST SEM 2025 CAMP\Prr 6 WELL ABANDONMENT\FtELD\224001_GINT.GPI
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013