Lincoln_Well Abandonment_20240710

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny W Hart 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 property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4446 B wells abandoned:
7b.Approximate volume of water remaining In wells 265 I al.
NC Well Conti-actor Certification Number PP g O� (gal.)
McCall Brothers FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Constructiog Permit#:
E H W24-01713 7c.Type of disinfectant used: HTH
List all app(icoble welt construction permits 0.e. UIC.County.State,variance.etc.)ifbrown 9 oZ
7d.Amount of disinfectant used:
3.Well uj:e(check well use):
Water S pply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Coolin Supply) RResidential Water Supply 1
( S/ g pP Y) pp y(single) ❑ Sand Cement Gr ut ❑ Dry Clay
❑industrial/Commercial I ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Trri ation ❑ Specialty Grout ❑ 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 40 bags
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stornwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothemtal(Heating/Cooling Return) ❑Other(explain under7 ) Slowly pour bentonite into well until full
4.Date well(s)abandoned: 6/4/24
52.Well location:
Century Communities JUL 1 2fl24 j
Facility/Owner Name Facility TD#(if applicable) 8.Certification: ;
7055 Stella PI. Stanley NC 28164 6/5/24
Physical Address,City,and Zip I am
arose o erti6 ell Cont for or Well Owner Date
Lincolh
B going this form, I hereby certify that the well(s) was (were) abandoned in
County r Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0I00 at-2C.0100 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(it'well field,one lat/long is sufficient) 9.Site diagram or nal well details: 1
35 25' 21" N8Q 59' 13" W You may use the bIdditi.
kofthispage to provide additional well site details or well
abandonment detaiYou may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable. For multiple it jeclion or rmn-water.supply wells
ONLY with the same construction✓abandonment,you can submit oneform.
102. 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: 220 (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: 6 (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: 40 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 Suuoly&Injection Wells: In addition to sending 4tc form to the
address(es)above,also submit one copy of this form within 30 days Pf completion
of well abandonment to the county health department of the County where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
I
fig.Screen length(if known): (ft.)
I
Form GW-3p North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016