Craven_Well Abandonment_20241002 (39)

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WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple Wells I
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1.Well ContractorInformation: 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) For multiple injection or non-water supply wells ONLY with the scone
cotnstrntctioin/abatrdonnnent,you can iubnrit one form.
4629C
NC-Well Contractor Certification-Number7b.Approximate volume of waterremaining 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#i N/A
List all applicable well permits(i.e.County,State,Variance,Injection,'etc)ijknoum
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 0Specialty Grout El 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 Bentonite Pellets 150 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•Retum) ❑Other(explain Linder 7g)" Surface Pour ''.= „„� ".• x a i I`
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4.Date well(s)abandoned: 9/10/2024 oc
5a.Well Location:
MCAS Cherry Point ~
Facility/Owner Name Facility 1D#(if applicable)- g•Certitic
PIT 6 MCAS CherN•Point, NC, Havelock,_NC 28532 Member 26.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CRAVEN By signing this form I hereby.certify that the ivell(s)was(vere)abandoned iri
County Parcel Identification No.(PIN) accordance with 15ANC4C 02C.0100 or 2C Well Construction Standards and
that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or deeimal degrees:
(if well field,one lat/long is sufficient) 9.'Site diagram or additional well details:
34.8980449795 N - 76.8886095582. W You may use the back oftlris'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 met/construction record(s)if available.For multiple injection or non-water supply
well ONLY with the scare construction abandonment,you can sttbntir ate form 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 100RW02 abandonment to the following:
... Division of Water Resources,.Information Processing Unit,
66.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.) 10a above,also submit one copy ofthis form within 30 days of completion
of well abandonment to the following:
6d.Water.level below ground surface: 8A 8(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&I 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 abandorunent to the county health department of the
6E Inner casing/tubing length(if known):' 15(ft.) county where abandoned.
-6g.Screen length(if known):
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P.\2024\224001-PW_PS-CHERRY POINT-2ND SEM 2024 1ST SEM 2025 CAMPIT 6 WELL ABANDONMENT TMLD\224001_GINT.GPI
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of EnvironmenCand Natural Resources-Division of Water Resources Revised Aug st 2013-
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