Onslow_Well Abandonment_20241025 (4)

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) For multiple ayection or non-water supply wells ONLY with the same
construction abandonment,you can subnut one fornc
4629C
NC Well Contractor Certification Number 7b.:ypproximate volume of water remaining in well(s): N/A (gala
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 o.e.County,Stale,Variance.Injection,etc.)ifknown 7d.Amount of disinfectant used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materia used(check all that apply.):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout "^ " ' 9B6ton4eeChips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout 0 r T y `� C� tClay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout 4 Lrj�Jrrii`I�Cuttings
❑Irrigation ❑Specialty Grout
Non-Water Supply Well: ❑Bentonite Slurry L-; _4.9ther(explain under 7g)
■Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets —5lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Storrnwater Drainage
❑Experimental Technology ❑Subsidence Control
7�. Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Coolin2Return) ❑Other(explain under 7g) All well materials removed and boring backfilled with
bentonite to ground surface.
4.Date well(s)abandoned: 9/19/2024
5a.Well Location:
MCB Camo Leieune _
Facility/Owner Name Facility III#(if applicable) g•Certification:
Onslow County,NC 28540,Jacksonville, NC 28540 ,Seutember 26,2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Ujte
O N S L O W By signing this form I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 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:
34.644035 N -77.402581 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well coti,tructionrecord(s)ijavailable. Forntultiplei*ectionornon-watersupply
ire//ONL Yu ah the same construction abandonment,you can submit one form 10a.For All"'ells• Submit this form within 30 days of completion of well
6a.Well ID#: TMW-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For lniection Wells: In addition to sending the form to the address in
I Oa above,also submit one copy of this form within 30 days of completion
6c.Borehole diameter: 1.0(in.) ofwell abandonment to the following:
6d.Water level below ground surface: 2.78(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 SUDDIV&lniection 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 abandonment to the county health department of the
6E Inner casing/tubing length(if known): 5(ft.) county where abandoned.
6g.Screen length(if known): 10(ft.)
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Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013