Lincoln_Well Abandonment_20221216

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WELL ABANDONMENT RECORD u For internal use01-My
1.Well Contractor Information: 5'^." Q—�J� WELL ABANDONMENT DETAILS
C_V-O n pa QC C I ^ 422
Ts.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same'
Well Contractor ame(or well owner personally abandoning well o nhitlher property) well construction/depth,only 1 GW 30 is needed Indicate TOTAL NUMBER of
J.� wells abandoned:._"_,
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NC well Contractor Certification Number "" `'0�`' 7b.Approximate volume of water remaining iu weII(s):S © (gaL)
1�_>I'Y Nro Knee_W e l fl r'I lit r ��wtf FOR WATER SUPPLY WELLS ONLY:
CompanyN 7c.Type of disinfectant used: 3/y l k Io e i rat_
2.Well Construction Permit(l:List all applicable well convructknpermits(Le.WC Cowl%Stat4 Vir ance-eta)rflataa7r 1 C '
7d.Amount of disinfectantnseJ:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural OMunicipal/Public O Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating(Cooling Supply) AResidentid Water Supply(single) ❑Sand Cement Grout Dry Clay
❑lndustrial/Commercial OResidential Water Supply(shared) Concrete Grout O Drill Cuttings
Oiui ation 0 Specialty Grout ❑Gravel
Non-WaterSupplyWell= ❑BentoniteShury 13.8ther(explainunda7g)
OMonitoring ❑Recovery
Injection-Well: TL For each material selected above,provide amount of materials used:
OAqufferRecharge ❑GroundwaterRemediation c1111l �[
❑Aquifer Storage and Recovery ❑Salinity Barrier ev � �
QAquifer Test OStormwater Drainage
OExpetimentai Technology OSubsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer } p 1 1
❑Geothermal Meating/Coo" Return) ❑Other(explain under 7 ) C.V.��i Le- i1J
4.Date well(s)abandoned:
59.Well location- 1 }
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Facility/OwkerRame, Facility IM(ifapplicable) S.Certification:
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Physical A\ddress,City;and Zip Q ,.y 1 Signature of ed Well Contractor or Well Maier Date
`!(��1� 1 v C '�" -��� • �S�� By signing this form,I herebv certify that the well(s)was(were)abandoned in
County Parcel IdentificationNo."D accordance ivith 15A NUC 02C.0100 or 2C.0200 Well Construction Standards
l and that a copy of this record has berm provided to the well owner.
5b.Latitude and longitude In degtees/minutes/seconds or decimal degrees:
(rf weU field,one lat/long is sufficient) 9.Site diagram or additional well details:
Q` 60 rr''1 41� � P 'Z�l� 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Artachwellcansimetionrecord(s)ifavagable Farmultipleinjecnonornon-xatersupplyxvlls
ONLYwith the same cmurruction/abmdonment,you con submit onefarm. 10a.For A Wells Submit this form within 30 days of completion of well
6a.Well IIM. 1�2-- abandonment to the fallowing:
q ( Division of Water Resources,Information Processing ssing Unit;
6b-Totalwell depth.. Q (fi:) 1617 Mail Service Center,-Raleigh,NC27699=i617
)� 10b.For Infection 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 i foIlowmgrc:
6d.Water level below ground surface. j 1 ({t) Division of Water Resoues,p nderground lnjection Control Program,
t 1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): 0 (fk)
10c.For Water Suonty&Iniectfon Wells: In addition to sending 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
6E Inner caskWtubing length(if known): (ft) abandoned
6g.Screen length(if known): V L)
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