Lincoln_Well Abandonment_20220607

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL,ABANDONMENT DETAILS
Alfred Kiesling Jr. 7a.For Geoprobe/DPT or Closed-;Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her propert)) well construction/depth,only l GW;30 is needed. Indicate TOTAL NUMBER of
3266—A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of waterh remaining in well(s): le V D
B & K Well Drilling Inc FOR WATER SUPPLY WELLS ONLY:
Company Name 9 7c.Type of disinfectant used: Ghlorine
2.Well Construction Permit#: 14 WOrq l ` 0 5 pp�I /�r
Lis'f all applicable well cowinu4ian permits&c•. UIC.',C'oway..State. 1 itriancc•,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use.check well use):
Water'Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public . eat Cement Grout O-ne rtonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 2<'sidential Water Supply(single) ❑ Sand Cement Gout ❑Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑hrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentunite Slurry ❑ Other(explain under 7x)
❑Monitoring ❑Recovery
Injection Well: 71'.For each material selectZe—,
e,provide amount of materials used:
[';Aquifer Recharge ❑Groundwater Remediation iLpq
❑Aquifer Storage and Recovery ❑Salinity Barrier l L Q
-
❑Aquifer Test ❑Stotmwoter Drainage. �_b 1 � cell'
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment race ore:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) v J
4.Date well(s)abandoned: /
Sa.Well location: �I,
/ )ftf8+rprn�ff
1.A,l/ 1�Q r tl CSC� !ry Ch
Facility/Owner Name Facility lD#1(ifapphcable) 8.Certification:
Phhysical Address,City,and Zip Signature of rtified Well Contractor or ll Owner Date
3 10a By signing this farm, 1 hereby semi`that the icell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 03C.0100 or 3C.0200 Well Construction Standards
and that a copra 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 IaVlong is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction recordtk)if availahle. For nudtiple it jection or nor-water.arpph well.
ONLY with the saute cwrso'uction/a1>andonnetrt,nou ran submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,information Processing Unit,
6b.Total well depth: �( � (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface; (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&lniection 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
6f.Inner casing/tubing length(if known): (ftJ abandoned.
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department ul'Envirunmental Quality-Division of Water Resource; Revised 2-22-2U 16