HomeMy WebLinkAboutLincoln_Well Abandonment_20221028 WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Alfred Kieslin Jr.
g 7a.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/deptli,only 1 GW i301 is needed. Indicate TOTAL NUMBER of
3266-A wells abandoned: '
l
NC Well Contractor Certification Number 7b.Approximate volume of water[remaining in well(s): (gal.)
B & K Well Drilling Inc FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorin e
r 7e.Type of disinfectant used:
2.Well Construction Permit#:�,l�y✓�-�'�'��/ Z
List all applicable well construction permits(i.e.UIC,Cormty,State,r$rianec,ctc)Ocnown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Bitesidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) oncrete Grout ❑Drill Cuttings
❑Irrigation ❑ 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 ❑Groundwater RemediationGlnd
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stomw'ater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal Heating/Coolin Return ❑Other(explain under 7 ) EdU Ile"
( g ) ( p g i� s
4.Date well(s)abandoned: V o2 y 0 C T 2 s 2022
1'
5a.Well location: / IftiCivfw;i3D Prcc5ogMj Un;t
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Facility/Owner Name Facility ID#(if applicable) 8.Certification:
6�216 <t" W — at3`aa
Physical Address,City,atu at Zip t, Signature of .ertif a Well ontra for r wa Owner
P ate
i�.V-1n e_'AN ?�T By signing this form, I hereby certify that t well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0700 or_C.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:
You may use the back of this page to provide additional well site details or Well
N W abandonment details. You'may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constrtictiorr record(.v)r,'favailable. Forutultiple ityecrio?r or?roll-watersupply x•e1Lc
ONLY with the same construction/abandonment,you can submit orre 1br m.
• 10a. For All Wells: Submit this Poem within 30 days of completion of well
6a.Well ID€1: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 IN tail Service tenter,Raleigh,NC 27699-1617
10b.For injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the,following:
6r1.Water level below ground surface: g0 (ft.) Division of Water Resources;Underground injection Control Program,
1636 U4ail Service;Center,Raleigh,NC 27699-1636
10c.For Water Surmly&lniectioh Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
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
6f.inner casing/tubing length(if known): M.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016