Lincoln_Well Abandonment_20230626

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WELL ABANDONMENT f RECUKI)
For Internal Use ONLY; ! I
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
1'4t-G h I t l^[.vt c S 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well ContrnctorName(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW=30 js needed, Indicate. TOTAL NUMBER of
2�73—A wells abandoned: I i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): l 00 (gal.)
'u;w c u S }A,E.,t,l-- Pv vvL 4() i FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: tl T H -
2.Well Construction'Permit#: E H w 2-3 ®0o7 Z
List all applicable well constnrctlonpermits(Le.WO County.Slate.Variance.etc.)ifknown 1-( � 1
7d.Amount of disinfectant used:
3.Well use(check well use): —
Water Supply Well: 7e.Senlingimaterials used(check all that apply):
t7Agricultural IoMunicipal/Public 0 Neat Cement Grout gBentonite Chips or Pellets '
OGeothennal(Heating/Cooling Supply) residential Water Supply(single) 0 Sand Cement Grout 17 Dry Clay
Oindustrial/Commercial °Residential Water Supply(shared) O Concrete Grout U Drill Cuttings
°irrigation 0 Specialty Grout 0 Gravel
___ Non-WaterSueply Well: _ - —=0-Bentonite Slurry ---- p Other(explain under 7g)- - -- -
OMonitoring LiRecovery
Injection Well: it For each material selected above;provide amount of materials used:
°Aquifer Recharge °Groundwater Remediation l SS O 1)S
°Aquifer Storage and Recovery oSalinity Barrier
°Aquifer Test fStormwaterDrainage .
°Experimental Technology °Subsidence Contrrol
°Geothermal(Closed Loop) 0Tracer 7g.Provide a brief description of the abandonment procedure;
°Geothermal(Ileating/Cooling Return) COther(explain under 7g) 5/o w F`� b 1 k L . y..,ti.,. ,
4.Date well(s)abandoned; r24l Z' JUN W 3 20 2 3
5a.Well location: r e r- ;
tVA
�t- �e j RiG isd;s i�q7 .Lilt+i.u,C‘"G
Facility/Owner Name Facdttylp#(ifapplicable) 8..Certification: . 1
10966,Ol :H k • f ey iv,ct <z'i�� - 3-28 2-
Physical Address.City,and Zip Signature of Certified Well Contractor or Well Owner Date
LrY-,col v. 2)9 714 L.
By signing this Arm 1 hereby certfy that the iuell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.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 tat/tang 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.WEL IS)BEING ABANDONED SUBMITTAL INSTRUCT IONS
Attachivellconstrudwnrecotd(s)ifasailable.For multiple injectionornon-watersupplyweils
ONLY with the same construction/abandonment,you can submit one form
10tt.j:or All Wells: Submit this form within 30 days of completion of well
6a.Well 1D#: . )A abandonment to the following
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 , (R.) 1617 Mail Service Center,Raleigh,NC 276991617
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10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1 L. (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: 11
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6d.Water level below ground surface: LS' (ft.) Division of Water Resources,Underground Injection Control Program,
2 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer easing length(if known): 30 (ft.) 10e.Four Water Sunnly&inieetton;Welis:In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
/j of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): / (R,) abandoned.
A
6g.Screen length(If known): �fT ((t)
FoemGW-30 North CarcotinaDenartmentofr,..r.rnn,,,..,lulu,..cw-n;.,;t..,....sur..,e.v�.......o.. ,.--.--