Lincoln_Well Abandonment_20240910

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1.Well contractor Information: ]/ WELL ABANDONMENT DETAILS -
L_ ,q)"Y 3 e1-1/1/ 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well C tract rName(Qr well caner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
1 wells abandoned:
4?2 NC Weel 'Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
/ CA// B 1 p 5, J n': FOR WATER SUPPLY WELLS ONLY
Company/// /7 Name r 7c.Type of disinfectant used:
2.Well Construction Permit#: � � •
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.)if known 7d.Amount of disinfectant used: 14 ©�
3.Well use(check well use): .
Water Supply Well: 7e.Sealing materials used(check all that applpt
0 Agricultural ❑Municipal/Public 0 Neat Cement Grout Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dg,Clay
❑Indu trial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout V6rill Cuttings
187rrigation • 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 0 7// C v 77/4`,5
❑Aquifer Storage and Recovery OSalinity Barrier llv❑Aquifer Test ❑Stormwater Drainage gL/`�/J ii"iA iul(id L T-/)
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer f // y 1,��s ����j�,�-y ���
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) / ) /I /� /` /�i
/// _ �• - ._ Imo*-+. ;_..
R.Date well(s)abandoned:
. r' 1 1.) [9?4
Sa.W II locat�io)nm l -,a /j/
Facility/Owner Name Facility iD#(ifapplica6le) 8.C ecation: af�'Ca?,lV�
33 ='l///yrer f i) i✓Mv I'P/ cam- )424," 7-I? 24
Physical Address,City,and Zip Signature nature ofCett'fed We I Contractor or Well Owner Date
. • By signing this form, I hereby cert(that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
•Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
• (if w 1 field,one lat/lorig is sufficient) 9.Site diagram or additional well details: •
• '.3 J, J f� 1' C) N _ eQ J. i 3 o C f' W You may use the back of this page to provide additional well site details or well
?f/ bETAILS
J CJ t J V abandonment details. You may also attach additional pages if necessary.
• CONSTRUCTION(DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructtorf records)((available.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 I D#: ; •I / . abandonment to the following:
n/� Division of Water Resources,Information Processing Unit,
• 6b: v
Total well depth:. �v (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
( 10b.For Infection Wells: In addition to sending the form to the address in 10a
.6ci Bbrehble diameter: h- J P (in.) above, also submit•one copy of this form within 30 days of completion of well
abandonment to the following: •
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: �}� ��j(ft.) 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
•
6e.Outer casinglength(if known t�e/AA /✓ft•) 10c.For Water Supply&Infection Wells: In addition to sending the form to the
g ) 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.
6f.Inner casing/tubing length(if known): (ft.)
•
` .6g.Screen length.(if known): (ft.)
• Revised 2-22-2016
form GW.30 • North Carolina Department of Environmental Quality-Division of Water Resources
form