Lincoln_Well Abandonment_20240212

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WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor bid,ormation: WELL ABANDONMENT DETAILS
4),Y1,l C k t,✓ 7a.Number of wells being abando led: /
Well Contractor Name(or well own personally abandoning well on his/her property) For multiple Injection or non-water supply wells ONLY with the same
construction/abandonment.you can submit one form.
33 ^G 7b.Approximate volume of water remaining in well(s): /Y (gal.)
NC Well Contractor Certification Number
C) yr LA { ,J s of 0Y11U..6 FOR WATER SUPPLY WELLS ONLY: /�
Company Name tiV 7c.Type of disinfectant used: I t ` r
2.Well Construction Permit#:—E{'it)Z) Q IP D3S
List all applicable well permits(i.e.County,State,Variance,Injection,etc)Via:own /7d Amount of disinfectant used l 19I'n�
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Munici blic 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) estdential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry er(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
['Aquifer Recharge ❑ 'DGroundwaterRemediation ( so Its a le+ccf'
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage ,
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ['Tracer _ tt `•`_��ll �/ Q,,, D-, at,,, ()IdR C
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Y vim/ 5
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4.Date well(s)abandoned: -512,/ r,e.. la-,- 6 e,s--,L i✓/�
5a.Well location:
-7-7 y53 0-uek/3) (-Are CLC--,
Facility/Owner Name Facility ID#(if applicable) 8•Certifiratio
-NO Oer'Ml (v) 1 l/s-izy
Physical Address,City,and Zip Signature of 'tied Nyelt2ctor or Well Owner Date
L(n(D 1 3 2D6(3 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 j0100 or 2C.0200 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:
3 Lfb) -f 9 t _� You may use the back of this page to provide additional well site details or well
to N �7J d�Jw W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the saute construction/abandonmens,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID#:
Division of Water Resources,Information Processing Unit,
/„ (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: !�0
10b.For Injection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6a Borehole diameter: (in.) abandonment to the following:
Division of Water Resources,;Underground Injection Control Program,
6d Water level below ground surface: (ft) 1636 Mail Service'Center,Raleigh,NC 27699-1636
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/ 10c.For Water Sootily&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): /�( (ft) 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. "[� F',,
6f.Inner casing/tubing Iength(if known): N fr (ft) " r °-�+ " z+ti
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vti
6g.Screen length(if known): ' 41 (ft) l' FEB 1 2 2024
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Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Waterr'irc ury to,n if',1 c`3r'^,oG i U tgcvisedAugust2013
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