Craven_Well Abandonment_20241002 (35)

WELL ABANDONMENT RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well.Contractor Information: _ WELL ABANDONMENT DETAILS
Trevoe Mizelle --- 7a.Number ofwells being I abandoned: N/A "
Well Contractor Name(or well owner personally.abandoning well on his/her property) For multiple injection or non-yatersupply wells ONLY with the same
corstructionlabandmrment,you can submit one form.
4629C: . . ..
NC Well Contractor Certification Number 7b.Approximate volume ofwafer'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#: 2869
List all applicable well permits(i.e.County;State;Variance,Injection,etc.)if town 7d.Amount of disinfectant used: NIA
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout ®Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) El Sand Cement Grout ❑Dry Clay
❑IndustriaKommercial ❑Residential Water Supply(shared) ❑Concrete Grout [-]Drill Cuttings
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
EMonitoring . ❑Recovery
Injection Well:. 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater.Remediation Bentonite Pellets 25 lbs.
❑Aquifer Storage and Recovery_' ❑Salinity Barrier
❑Aquifer Test, ❑StormwaterDrainage
El Experimental Technology [.]Subsidence Control
❑Geothermal(Closed Loop) El 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: OCT L, 2024
MCAS Cherry Point
Facility/Owner Name " Facility ID#(if applicable) 8.Certifica ion: . ��:�;;d•n i_}
PIT 6'MCAS Cherry Point, NC, Havelock,=28532 SeDtember 18.2024
Physical Address,City,and Zip Signature of Certified Well Contr nor r ner Date
CRAVEN By signing thisfonn I hereby certify that the ivell(s)ivas(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15ANCAC 02C.0100 or 2C Well 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:
34.8982262303 N 76.888279964• �, 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For nndliple hyection or non-water supply
well ONLY with the same construction ahandonment,yott can submit one form "10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 100GW04 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 18 (ft.). 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Iniection Wells: In addition to sending the form to the address in
l0a above,also submit one copy of this form within 30 days of completion
6c.Borehole diameter: 2 (In.). of well abandonment to the following:
6d.Water level below ground surface: .10.12'(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 Suaniv&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
county where abandoned.
6f.Inner casing/tubing length(if known): .8 (ft.)
6g.Screen length(if known):. 10.(ft.)
P:\2024\224001-PM-PS-CHERRY POINT-2ND SEM 2024 1ST SEM 2025 CAMP\Prf 6 WELL ABANDONMENTIFIELD\224001_GINr.GPJ
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised Aug st 2013-