Lincoln_Well Abandonment_20240423 (2)

WELL ABANDONMENT RECORD
Far tmem:d v�oNt.l�: I .
This foim can be used fir single or nrulliple)sells
1.Welt Contractor Information: WFLL ADANDONNiFNT UT:TAMA
Brian Ewing 7a,Number of%%ells being abandau Ide 1
Well'Codtnclor Maine(or well o,crer pcaonalky abandonitt;,tvil on K9111er Prolxa)) Far rrridnpfe er fecarme to ry ra-,rctf r sirpo, wells ONLY utrb Ike smie
runt<rrrrchrNi.i arcP ium�ar,lYlr ctur nilmim ogle fruan,
4240—B
NC Well Contrtaort,nlfadioo Nnribea 7b.Approximate volume of stater rcmah%in}in n ell(%): (god,
SAEDACCO FOR WATFR.SUPPLYWF:LIS ONLY:
Con puny Name 7c Type of disinfectant used:
2.Welt Construcllor Pcrmft N:,
LW RapiAruldenelllwjri7arj.4Cvarrh,Slide,i'arjame.br•JecHon,elc.)ifknocrrr 7d Amount
3—Welt use(check%vell usa):
Water Supply Well: 7e.Scaling materials used(cheer,all that apply):
DAericulturat gblluricip AJPtlblic M Ncat Ccmcot Grout ❑Bcmonitc Chips or Pcllets
❑("scothctm d(licatingl('ootino Supply) ❑Residential Watcr Supply(single} ❑Sand Cement Grout ❑Dry CL•ry
0htdust".0nmecreial ❑Residential Water Supply(slLaad) ❑ConcreleGrout ❑Drill Culling%
❑hti team ❑Specially Gruut ❑Gr�%el
Non-Water Sul ph Well: ❑Bentouite Slum, ❑Other(esplainunder 7g)
49Monitorine ❑Recovery
Injection Welt: 7f,For each material selected abofe,provide anwnrit of tuAterials ukd:
❑AquiterRecharge ❑GrtiuiuigrterRentediation Neat Cem.:941b ,Wtr•7gal. Sand Cem.•lb ,Wtr:gal.
[]Aquifer Storage atki Rr:cov'en, ❑Salinity Barrier
❑Aquifer Test ❑S lortrnvater Orsiriaee
❑Cvperintettlal Tctibnology 17Subsidet><e Control 7g.Provide a brief description of the abandonment prr►cedute:
❑Geoiliennal(Closed Loop) ❑Tracer
TREMI GROUT FROM.THE BOTTOM TO THE SURFACE
❑Gcothenual(Heacingr'Cooling Retnm) ❑Other(es lain under 7r)
d.Date stell(s).:•iti andoncci: 3-25-24
5a.WA location: -APR 2 t'
Warlick's Grocery
fadlityiChvmrNarrc FarilOy iD9(fapplirablc)
2673 Plateau Rd. Vale, NC 28168 Brian_ Ewing 4/2/2024
PiLysical Addtc4,City,and gig Well Coutrr,tar r•r:.11 Oum-r Dirk
Lincoln By signing this farm; I bereby cerdf)that the nre)lfs) Crux(u-eMl ahandoned in
Comm, Parcel I&nlifi'61jnu No.(PIN) accorclrn ve will:I i.4 1C'lC 02C,010ra.vr 2C.0200 ff ell Cbn81neceivn Stawkirds
avid lJrn1 a conroflbfs tecvrd krrs been provider!io 1Jre well onuer.
. I atihtde and lunetudc in dcrrces(minuteskcconds or dechri al degrees:
(tr.,cn r5etd,one LlUtnng l.:,alt;c ra) 4.Site diagram or,additionalnell deralls:
You nta} use Ilse ba&-of this'page to provide:additional%still site details or vv6
lV abaudoiunent details..You tuay also allacb additional pages if mcessag-
CONSTRUC-1'ION DETAILS OF WELL(S)RISING ABANDONED %URMriTAL iNSTRU(:TiOYS
Ilrach lid)rorsrr ,cneort revurd ]j)'arvr 1d,1e. rev twlnple byectimr'ur ritn•uxucv su pit'
melts ONLY rrddi rlxr svrn�rwrsrrurlroa+i�orrch.❑rr.rcnre,i�r ran svbnul are jbnrr_ ilia. For All Welly Submit this furor uftltin 30 days of eontplction of aril
Ga.Well[D_.
#: MW_8 abandonntcnl to Cite rollo%ving;
Division of Water Resources,Information Processing Unit,
(ft.)Gb.Total well depth.
35 1617 Mail Senice('enter,Raleigh,XC 27699-1617
lob.For Iiiteolon Wells'. In addition to sending the fom to the address to 10a
fe.Borehole diameter:2 (in.) above.also submil orte Copy of this form within 30 days of completion of well
ab:andountcm to tits folloWirtg:
Gd.Water level boast ground strrfacc: (ft.) Division of Water Rssounces;Underground Iujectfon Control Program,
163E Mail Scnicc(enter,Raleigh,NC 27699-1636
6c.Outer casing lcn h(itlmp%%n): (ft) lne,for Waggr.5u tnh•.0 infection 3�11s: Io addition to seriding the font to
the address(es) Iboye. also submit one copy of this fora within 30 dais of
completion of%cell abandomnent to the county beatlb deparmrtmii of the county
Gf.Inner casingliabing tength(if lmunn): (f1.) %nccrc abandoncd,
Gr,Screen length(if knostn): (ft.) I
Form G W,30 North Carolina Departmcni of Pnviroonmi:and Narumt Rcsomccs—Dlvisfon of Water Resomm J Revised Augusa 2013

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WELL ABANDONMENT RECORD_ For lmmralUscONLY.
Tidsloim can be used for single or multiple wdis !.
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1,Wdl Contr,amr information:' )YELL ABANDONMENT-DETAiLg I
Brian.Ewing 7t i`i berofircllsbeingabandonld:li l
1YcltC.pmadmrNanie(of natn%re.!1pclsanallyaw.sdalt l,%ctl.anI&ILrrpiulicrty).. fa• mufople fiver ar .or noimitifir 1 sirp'ph, wells-, -ONLY with mce 71.ti7 si
' - Cy}71YfrrrCfkYl/RbNP[frlJlNlt'r1�)ClN42UP57iZV)17f'tNl+.ejftnri,
4240-B:
11C Wc17 CbnlfacturCettiflcatioti Nnnr6er '71t.Apprnt imltte~dome of etater riernaininr;in n'ell(s};. (lGat)
SAEDACCO FOR WATER.SUPPLY iI FLLS.ONI:Y:
Conrpatr}Name lc.Typeof dhinlectaut used-
2.Well Construction Permit H:,
LL.7 rrfl rrpf�lk�vbtc a elf}armfl+(i.! S;,ae•J'arin x c:Ly'Nco'or,rl�)tJ Frrown. 7d..11riotmt of illsinfectdnt tLXd:
3.�YeII use(elredr n•cll u.�c}:
Water Supply Welk ?e.Scaling materials used(checkall shut npoly):..
pAgritulttitat ljNhjnjdjrXjl&kjbIicL d1 NptCcmeni Grout ❑Hcrrtogitc Chips or Pcllm( "
C]Cmotknimt(146tinglCooling Supply) ❑itcsidcntial Water Supply(single) 13.Sand;Cenlrnl Gmut i ❑Dry CL•1y "
❑huidsUialfCorirntcrcial Mcsidcntisl Water Suppl}y(sW,red). ConereteGrout L1 Drill Cuttings
❑irri ution ❑Specialty'Grout p Gr1�el
Non:WaterSupplyNyvil: dBentotuteSium j ❑'Other(e�-plain under 7g).
Monitoring. ❑itecaverv..
injection Well; 7f.For each tn'ateri;41 scletted'aboce,pi*idc amount af.tuaterials weed;
❑Agt!kerllcdtarge. Renlediiition Neat Cem. 941b ,Wtr•7gal.. Sand Cem.•lb ,Wtr:gal.
OAqud r Storege and ltecovety 6Saliriitg Darner ;
13Aguifei Test' ❑Slouinvatct Drainage
❑Eyrerintenlal Tctihuologv I]Snbsideme Conttnl 71P Provide a brief description of the abandonment procedure:
DGeothermal(Closed Loop) - L" bcet
TREMI GROUT FROM:THE BOTTOM .TO THE SURFACE
Meothemral(Heatipg Conlin Retum) ®Other( lain under 7stl .
4.Dateweli(s).abaudoncd_ 3-25-24 1 APR 2 ,. /0
24
;a Well location:
Warlick's Grocery
radht),hvmr Name racilrt,.•MR(Fuppikabic)
2673 Plateau Rd. Vale, NC 28168 Brian.EwI n 4/2/2024
I,
Physical'Addrem.City,°acid Zip sqrojjarC it r ctitaw IveitGuar;aur rr'all'givmr D;mc
Lincoln By sig11t1{g this fartui J hereby certify 1/?at llle ii ell(s)wrrs(�verw)mhwrdoned in
Clouuip PamelldaWficatim No.(PIN)' 00clinlniimivrdlili:1.1C:iC.02C.0100.or2C.02611 tcell:Cunsh77cfion"Slrinfkliils
"aid IN it a copy pfllds record liar be ir Provided to-dre hell oivnrrr'
Sb.I ititudeandNugitudeindegmes/minumslseconds'erdecint7l'degreck
(ir,ccll r'r�;lit,0t7 Wong is514 O011.0 9.,Site.diagram or additional well details:
You ma};use.tlie bad•.of this page to'priivide additional bell site'dztails;or sell
N W .abandonnieurdetails..You tuay aLso aitacll additional pages if aezessan'_.
CONI;TRli(-rioO Y-DrTAIt-,;OF WELLdSI BEINC.ABANDONED' SURNIMAL iNSTRUCTfON+
:tttadt 11Cll.rrirvlrrlC'1irrt1 remrd;s)ifavnlldk .ror multiple byeCrimr*Er ram•vwli7 sufplp
uvfk ONLY u1thrJk+avinriacstrrrfiorc'abmr�hrlrivr�u��,rl nrd+lriitwrennii 10a:For All Wctls: Suhmil"this fotnt within 30 dap;of;toni(tletion of itrll
4 Wc11 ID .MW-10 aliandonm itt to the Following:
Diy'ieion of AYatcr Resources,Lofonnatioo Pruct:Wng,Unit,
6b.Totalst'ell depth:45 (110 1617 Mail Seriiec Cedtcri Rj1dgti,NC 27699-1617
10b.Tnr•inlectlott Wells: In addiGoa.to sending dte font"to the addiesi in 10n
6c.13otCtiole dianutcr:2 pu, abut-c:, tilso subudi one copy of this fonu ttithm 30 da}• of completion of well
y abandonment to the follottill"'
f1d.WaterIcrcl.bclaw grauntl curl rcc: (ft. Dhislouof*i IerResouries;Uuditiound injection Cout6ol-Pr6gram,
1636 lltail Senicc Center,Ralcigh,NC 27610 1636
Ge Outer casing len,Tth(itlmo`r ts) ( .) 10c. 'nr•Water S ijnl•.F Tnieerlon��ells; io addition"to moding the font to
the address(es) above. also atibudt'Otte copy of this form wlibin 30 dj's of
compicdoti-of m-ell ob:mrdomnem to the county health deparimcni of the county
6f.inner casin■tnhiti■length if lcnou•n• �rhetc alrtrrdortcd, I
6g Screen length(if known): (ft.) .
Foun Mr.30, North CaroWn 93cpgnlu m of Entlromncnt and N:uuml Rtsouiccs-Dlvis[on or Watcrltesonrms. i Revised Aqua 2013
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WELL ABAM®NMENT RECORD rarltncnialt1wMY; I
This form can be used for single or multiple ivells
I.Well Contractor hirortnation: WELL ABANDONNIFNT DETAILS
i
Brian Ewing lit.Number of eerlls be,ittg alninduned:1
te%VellContnaorNaim(or well oe�petsa,t.�l1}aWrlimibi;aellon]dstltrrpralxny) fw• r,17ripir. U,eea.,Wr or roan-warer'supply 4dLc ONLY with Nt swna
e'�NiSfrifChi81i711`irliYjiNI1Ne9lf,Tarr our,�artxn!(iuirfe,rut,
4240-B
NCWctl Contraaor Cori lfiattion Niutbci Al.Approximate volume of water remaining in vvcll(s):' (gal)
SAEDACCO FOR NVATF;R.SUPPLYWFLLSONLY:
Compaq Name 7c.Type of dimiliketant used:
2.Well Construction Permit d:,
LWaliriijith able wellpe mmy(i.e Cw, Siae,J'urin_ce.brfediriq e1c.1 tfliwwrJ jd•Amount of dLiinfetitslllt used
3.Well use(chcdievetl use):
Stater Supply Well: 7c.Scaling materials used(clicck all iliac apply):
❑Aaricultiltal ❑Ntur icipali ttblic N Ncat Ccmcut Grout ❑Bcnionitc Chips or Pcllcls
❑Geolllenntl(HrminglC'noling Supply) ❑Residential Water Supply(single) ❑Stave Centenl Giant ❑Dry Cloy
0Iruttistrial1Coinmic''mial ❑Rcsidmbd Water Supple•(sluircd) ❑Conetcte Grout ❑Drill Cuttings
❑Irti'•lion ❑Speciafty Grout ❑Gravel
Non-Water Supliky Wall. C1 Bentonite Slumr' ❑Other(e.,plainunder 7g)
119Mmiilorine 1:311ecovery
injection Wctl: - X For each material scicc(e'above ptntidc[rtitottnt of.nuiterials used:
❑Aqui(erRccliargc ❑GroundtiaterRentediatimr Neat Cem.:941b ,Wtr:7gal. Sand Cem.:lb ,Wtr•gal.
❑Aquifer Stonige aixi Recovery ❑Salhtilp Ramer
❑Aquifer Test ❑Slorinvater Drailmed
❑Eapttimeutal Ti chuotgLm ❑Subsidence Contral 7w provide a brief-docription df the abandonment procedure:
06eoihemlal(Closed Loop) ❑Tracer
TREMI GROUT FROM THE BOTTOM TO THE SURFACE
ClGeothemtal(He<icinR:'Cvolins Return) ❑Odtcr(es lain under 7J;)
d.Date wcll(s)abandoned: 3-25-24
ia.Well location: APR 2 :' 2G24
Warlick's Grocery
S.Ce•elRcatlon: ?
ilill -.r•ss-,a;; •r
racroicrxr Nmns ra:ility It)A(ifapplicablc)
2673 Plateau Rd. Vale, NC 28168 Brian_ E i n 4/2/2024
Physical Address.City,and Zip S%ailnR cv ctliliod%Vell Caitimant r r.'t11(hvwr Dale
Lincoln, By stgutng this form, I hereby certify i1xi the irell(sJ cues(icere)abrwdoned ru
Cauuky I'arrel ldcnIjft 3tlou No.(PINj accm1ame irith IS-1 NC IC 02C.0100.ur 2C•0_00(yell Cinosimclion Efimrkirvls
and(lrat a cop)r ofiltis record lxu been protaded io tire hell ou-ner.
5b,1»ltitudc and longitude in degmeslminuteslseconds ordccimaf egrecs:
(Irwcll ra1d,61w boong Ic nfllOot) 9.Site diagram or additional well dctalLc:
YOU map lue[lie bail:of this yoga to provide additional well site details or well
N SY abandotunent details. You tuay also attach iidditiotml pages if ibucessaty_
CoNs,rRll(.'flON DETAI➢5 OF WELL(S)BEING ABANDONED SURNTiTTAi.iNSTRUCTfONS
:111ru1r trr1J crJrvtrrrclrzrrt mcnrdfa!Jj'oivilrarle fiv muihplr i�jrciica:rN•rr�n•u•utrr yrjFdp
a~idv ONLY uirh rt s,nn�'rvrrsrrr�rrom'uha rekxrNeKet11 a cvu nrhmir curejunq_ 10a.For All Wdk: Submit Ihls forth within 30 days of completion of urll
63.Well ID#:MW-IA Oxmdounicut to the following;
Diy'isiou of Water-Resuurcm,Information Prucessitiv Unit,
61).Total n'ell depth: 42 1617 Mail Service Center,ltalciRti,1V C 27699-1617
LOh.ror Tnleclian«'ells: in addition to sending the form to the address In [Oa
6c.Borelmlc dlaincter.2 (iu.} above.also subndi one cope of this form within 3O days of completion of well
abandonment to the rollon•ing:
Division of\VoterResources,Underground hijectiun Control Prdgratu,
641.Water level baton•ground surface: (ft.) 1636 Mail ScjAicc Center,Ralciih,NC 2769 9-1 63 6
Gc Outer casing length{if Imnyyn}: (ft:) Inc.Fnr Water Sunuly&Ti��ion 3Lvik: In addition(o seceding the form to
the addresses) above. also submit one copy of this fort within 30 days of
completion of ivell ntimdonmrnt to ilia county healib dcparincul of the county
6L Inner casing1tubin„length(f known): (tY.) wilco abandoned,
6g,Screen length(if known): (ft.)
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Form Gti11-30 Nonh Carolina Depinwm of Pnvlronmcnt atxi Noma(Rasoiures-Division of Watcrftmamcs I Revised Akm6 20 t3
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