Craven_Well Abandonment_20241002 (33)

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WELL ABANDONMENT RECORD For Internal Use ONLY: I
rt b 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 Name(or well owner personally abandoning well on his/her property) For multiple injection or non-watei_supply ivells ONLI'tvilh the same -
coutrtretimn/abandonrnten,you can submit one fonn.
4629C
NC Well Contractor Certification Number
7b.Approximate volumef of,water remaining in well(s): N/A (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used: N/A
2.Well Construction Permit 0: N/A
List all applicable well permits(i.e.Co nly,State,Variance,Injection,etc.)iJknoun 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
❑IndustriaVCommercial ❑Residential Water Supply(shared) []Concrete Grout DDrill 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 ❑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 0 C T 0 2 2024
5a.Well Location:
MCAS Cherry Point j w I
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
PIT 6 MCAS Cherry Point, NC, Havelock, NC 28532 September 18.2024
Physical Address,City,and Zip Signature of Certified Well&Wta u '✓zl Owner Date
CRAVEN By signing this jonn I hereby certify that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C Niel/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 laOong is sufficient) 9.Site diagram or additional well details:
34.89803 N 76.88839 W You may use the back ofthis page to provide additional well site details or well
abandonment details. Your may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. Fornudliple injection or non-water supply
well ONLY with the sone construction abandonment,you can submit one form 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:" DPS-05 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 17.5 (ft.) 1617 Mail Service Center,Raleigh,NC 2769971617
10b.For Iniection Wells: In addition to sending the form to the address in
6c.Borehole diameter: 1.0 (In.) 10a above,also submit one copy of this form writhin 30 days of completion
of well abandonment to the following:
6d.Water level below ground surface: 10.31 (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 abandomnent to the county health department of the
6f.Inner casing/tubing length(if known): 16.5(ft.) county where abandoned.
6g.Screen length(if known): 1
P-.\2024\224001-PIE-PS-CHERRY POINT-2ND SEM 2024_IST SEM 2025 CAN P1Prr 6 WELL ABANDONMENT FIELD\224001_GlNT.GPJ
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013