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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 ?aA*r;'_K 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