Lincoln_Well Abandonment_20240710 (2)

AWELL ABANDONMENT RECORD For Into nal Usc ONLY:
r
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
4446-B wells abandoned:
NC Well Contractor Certification Number 7h.Approximate volume of water remaining in well(s): 5 (gal.)
McCall Brothers FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit#: E H W24-01539
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: oZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothemtal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 3 bags
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Slowly our bentonite into well until full
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
4.Date well 5/30/24s)abandoned:
$a.Well location:
Shawn P Finley
Facility/owner Name Facility ID#(ifapplicable) R. ertification:
Lot 54 Executive Cir Denver NC 28037 1AA df;5:!
Physical Address,City,and Zip tore of Ce ed Well Contra or or Well Owner Date
Lincoln
By signing th form, I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 1C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one]at/long is sufficient) 9.Site diagram or additional well details:
35.5414609 N —80.0024645 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 if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
IOa. 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: 50 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in i0a
6c.Borehole diameter: 2 (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: 20 (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&Injection 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
6L Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

1
WELL ABANDONMENT RECORD tWrlj.
CscONf,'
This form can be used fa single or mldtiple µells
1.W'ell('antracuir Infnrnatite: ANbONMFNT DETAI[S
Brian Ewing 7a.Number of wdls being(abssiloned: 1
Well Connactor Nang tot well OwnY ptscinath-Aunilumng v eft on lowlier piopem I Pea mrrtrrph etlecbcur ". Yuppl. cells ONLY i.uh rho 'anle
conorwt(mo ahwi himmew.I.,,:, ,i,uhwt(one Jimw
4240—B
NC Wdl CoritaciorCeniftcalitm Nanticr 7b.Approximate swlmse of watrr.emainint in wdl(s): 1((al l
SAEDACCO FOR W''1TFR SI PPIA W FIA SONI 1:
Convan, \.aik 7c.7\lic of disinfectant used:
2.W tit Constnu l"n Ptn'nut 0:,
i u r, i, ' ,aM..�'iak'.I.rnarnce brµ'eixrn,elm.i d Ahura
7d, lmttant of Jisinfceanl uxd:
J.Well use(check:well rise):
Water Suppd,.Will: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑NhmtcipslrPubhc 2 Nr•u Cemcn!Grote n I►erdonne Chips or Pellets
❑Geolhcmul(Hcanns:'0N.41III Stq*',) DRcsrden nal Water Suppl imriglc) ❑ Sand('et»etu Grout ❑ Un CIa..
❑Indusinal'Commcraal ❑Rmidvitud Water Supple 1,hared) ❑ Concrete Grout ❑ Dnll Culltrip
❑Im •timo ❑ Specialt)Gruul ❑Gras el
Non-Water Surilih Well: ❑Bemonite Slurry I 1 Other(0plam undo'gl
l9Ntonuonni ❑Ralxrn
Injectinn Well: 7L For each nl:ltt-ci:d si'I.•ttcd ahnse,prinidt-Aom.ont of materials used:
❑AqudcrRcdurRc ❑GmundwalerRensedimion Neat Cem. :471b ,Wtr:3gal. Sand Cem. :lb ,Wtr:gal.
❑Axp iler Storage and Recos en ❑Saluun Hamer
❑Agmfcr lest ❑Slonlm:NerUreulage --
❑Expenniental I echnoloLn ❑Su bsidciic C oitrol
71!.Prim ide a brief description of tlar abandonment prwct(lure:
❑Geothemral(Closed Loops ❑Tracer
TREMI GROUT FROM THE BOTTOM TO THE SURFACE
❑Gmthcreiril(Heating-fooling Reim) ❑O ail am under'' )
4.bate welllsl abandoned: 5-3-24
Via.Well location:
Wellington Property
Fxtliryr'owwer Nano scan.Inw(;rappiicabk)1419 Gaston St. Lincolnton, NC 28092 R_Y ri a.n win 5/14/2024
PMsical Address.Can.aid Zip .. D wt
Lincoln By sigrung tilts fi)rnm, I hereby cemp-that the well(sj was(were)abmickined sit
Count. 1'meel We fit if"wit No.(PR4) ac<rinhnKv wilt 114.N't.4C 0:('.0100 or Y- OXV Re'll CansAwetum Vcmdurds
and that a chips of this record Am been,pr mwkd to ode well owner.
I%.Latitude and longitude in degriceslminuteslweainds or decimal degrees:
Id..cll fold<nt Ln M,u i...iiHi iv; 9.Site diagram or additional well details:
You mat tnc the back,of this page to prom de additional well site details or well
N W' abatdountera details. You uta% also attach aMitiuiial pates if neccssan
CONSTRIY'TION DETAILS OF W ELUSi BEING ABANDONED S[BMiTTAL INSTRUC"TiONS
.lr4xlr+ell cvarlrrclHm rrcr,rds+{l sirmha'ik. lwr mulrrp7r mjecnrur ru am-+�trr nrpph
+<•i1.rONt.1'+nhrhe io canwhwau vre loom IUa. For All W'ckb: Suhimi this loan uithtn :-i daNs of completion of ual
6a.Well ID=:TMW-1 :.batdonnicnn to the fhlh,u,nt;
Di,ihian of Water Resources.Information Processing)'nit.
61t,'fatal well dcp111: 47 (h,) t617%tail Senior Center,Raleigh.%('27(i99-1617
10b. For Iniwkin Wclls: III ark u"i to seldolc dw form Io Ilk:ddlcss III lu;r
abu,kc. alw subnot orie cop% of this form wilhui :c days of cooiplclknt(il ucll
bc.m.,vtuilc diamcicr:2 (n.) aba"doluneill It)file I(AlLmow
M%kion of Water Resources,Cndco-LnKiod Ini tion Counsel Pntgram.
bat.W atcr k el hchiw _m oilki Vlrfacc: (ft.) 1636 Mail Senior('enter.Ralci_i.NC 27699-Ifi36
10c.For Water Sumps & Iniectitn WeRs: lu addueon to sailing the fomi to
6c.Outer casingleriatitldlaown): (ft.) the addressees) above. also submit one cope of this fomi I%ohm to da}s of
completion of iscll ab:induiu»ent to the courts heabh dcpannicni of the cam
eficrc abandoned
6f.Innercasinr0ubin_len_th iif Icnns.ni: (ft.)
6g.Screen length lit•Lnu..i t:10
Font GW-itl Nnnh['arolim Ihpunurn of En.irounicn aid Nounkl Resources-Dii islan of Water Rcsoarccs Re,ised hugusi HiI t