Lincoln_Well Abandonment_20221205

WELL ABANDUAMEAT KLt C ORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
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G b'/_&e— C Frce,VV G G S 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- 0'is needed. Indicate TOTAL NUMBER of
2 q?3 ^ wells abandoned:_
NC Well Contractor Certification Number 7b.Approximate volume of water remaining
ei aining in well(s):�! (gal.)
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a,I C c,S oe—C f 0L PC,/n FOR WATER SUPPLY WELLS(ONLY:
Company Name w I . ) 7c.Type of disinfectant used: I �Tf
2.Well Construction Permit#: 2 2—— ©571 1
List all applicable well construction permits r.e.UIC,County,State,Variance,etc.)ifbrown
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 a'Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) M esidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri fation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
-ElMonitoring DRecovery -
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation `z O s
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
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[]Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonme procedure:
❑Geothermal(Closed Loop) ❑Tracer 5 Q�
❑Geoiliermal-(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned:
- 2022
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5a.Well location: 11 nn V
Facility/Owner Name L G Facility ID#(if applicable) 8.Certification:
?0l 2- -13 la*J,gqJ, DenverA),G,2gn3�' ��� /233 2-Z
Physical Address,City,and Zip Si 'of Certified Well Contractor of Well Owner Date
Ln eo L 572-g y By signing this form, I hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standard_s
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.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
N 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 records)ifavailable.For multiple injection ornon-water supply wells
ONLYwith the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Weil ID#• abandonment to the following:
/ Division of Water Resources,Information Processing Unit,
6b.Total well depth: �� (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
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: 2® (ft,) Division of Water Resources;Underground Injection Control Program,
�Q 1636 Mail Service;Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): / I. (ft.) 10c.For Water Suonly&Ini I on Wells: In addition to.se.nding the form to the
addresses)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): A)/ t/� (ft.) abandoned.
6g.Screen length(if known): Aj LA-00
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016