Lincoln_Well Abandonment_20230724

WELL ABANDONMENT RECORD For Internal Use ONLY..
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
In 6, fi G t/t ,< 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 I GW-30 is needed. Indicate TOTAL NUMBER of
3� ✓�A wells abandoned: /
NC Well Contractor Certification Number / 7b.Approximate volume of water remaining in well(s): S. 1— (gal.)
I/I•S %- S731A (^l e`! O kl�w�J FOR WATER SUPPLY WELLS ONLY:
Company Name
p Q 7c.Type of disinfectant used: �L to a D C Jo,'; -e 6 S oI
2.Well Construction Permit#: 4—::' W 1 7 7 —Q r l c-A ,v I n'e
List all applicable well construction permits(i.e.UIC County,-State, Variance,etc)ifknown d
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 Grp_trt ,� a -o0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) C�esidential Water Supply(single) ❑ Sand Cement GfnuL �r r Clay
❑Industrial/Commercial , ❑Residential Water Supply(shared) eConcrete Grout. ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout JUL 2 .4 2023❑ Gravel
Non-Water Supply Well: ❑Bentonite SlI ,� 'I q Other(explain under 7g)
❑Monitoring ❑Recovery " ? �f " ?t4j `-A
Injection Well: 7f.For each material selectedbrovide amount of materials used: /
❑Aquifer Recharge El Groundwater Rem elf
f Ca N �(S orD�a� O A c Y ge 6-1'Oek�
❑Aquifer Storage and Recovery El Salinity Barrier n /-+ew
❑Aquifer Test ❑Stormwater Drainage 5 ` 01 I(J �4� l G
❑Experimental Technology El Subsidence Control JV
7g.Kovide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g) /�I d &/& Ld / C --S c
de
—7 W L(/ op 4S�t ��` o 7�Z o .�n.I cJ e.l�t�.�'10-
4.Date well(s)abandoned: 7— / — Z 0 2,3 Q YA Q • 0��5 ' e /tI
_ Sa.Well location: nn _ � n � 'sf
Facility/Owner Name Facility iD#(if applicable) 8.Certification: P O kd /���lve4 `�
2r L/ o C a .- A-de c l kb Re 4�P L�,1 t:�1�,�0� eX »fCCC
Physical Address,City,and Zip' i a /�T��r/�L Signature of Certified Well Contactor or\ Il Owner Date
Z Z.6 T By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A 1VCAC 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:
(ifwell fiield,��one
//lat/long is sufficient) / 9.Site diagram or additional well details:
.5.rT(O �� 3 e N P 1 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 constriction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the sane construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: Je0 (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: -7 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
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.)
Fomr GW-30 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016

ROY COOPER•Governor
INC DEPARTMENT OF KODv H.KINSLEY•Secretary
HEALTH AND HUMAN SERVICES HELEN WOLSTENHOLME•Interim Deputy Secretary for Health
.
MARK T.BENTON•Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
June 20,2023
Lori Benfield
2140 Country Club Rd.
Lincohrton,NC 28092
RE: Approval No.WWM1650
Abandon Well without Removal of Debris
2140 Country Club Rd.
Lincolnton,NC 28092
Dear Ms.Benfield:
On June 20,2023,the On-site Water Protection Section received your request to approve the abandonment of a
water supply well that currently has piping/plumbing inside the casing,and removal of this material is not an option.
The approval request is for the abandonment of one(1)water supply well at 2140 Country Club Rd.,Lincolnton,
NC. In your request you indicated that due to the depth of the material and uncertainties surrounding the ability to
remove the material in the well,properly abandoning this well per 2C.0100 regulations is;not an option.
Based upon available information provided by the certified well contractor you are approved to abandon the well
without removing any material by pouring a cementitious grout into the portion of the well containing the piping and
properly abandoning the remainder of the well to land surface,in conformity with the teoirements of 15A NCAC
02C.0113. A copy of this approval should be attached to the required Well Abandonment Record(GW-30)as well
as the county well permit at such time that it is issued.
The approval of this variance does not affect any of the other requirements or limitations of the Well Construction
Standards,including but not limited to the requirements in 15A NCAC 2C.0113(b)to repair or to abandon any well
which acts as a source or channel for the migration of contamination or to your responsibility to comply with any
other applicable Federal,State,or local laws or regulations. Furthermore,the granting of this approval is for the
well location only,and in no way relieves the owrier or agerit from other requirements of the North Carolina Well
Construction Standards,or any other applicable law,rule,or regulation that may be regulated by other agencies,nor
does it imply sufficient water quality.
If you have any questions regarding this variance,please contact Wilson Mize at(919)-270-9665
Sincerely,
Wilson Mize R-E.H.S.
NC DEPARTMENT OF HEALTH AND.HUMAN.SERVICES DIVISION OF PUBLIC HEALTH
LOCATION:5605 Six Forks Road,Raleigh,NC 27609
MAILING ADDRESS:1642 Mail Service Center,Raleigh,NC 27699-1642
www.ncdhhs.gov TEL:[phone] • FAx:[phone]
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

i
WELL ABANDONMENT RECORD
or Internal Use ONLY:
I.Well Contractor Information: 2 LL ABANDONMENT DETAILS
n 7 JUL 2�. �
VIA r11 G��' � " � 7a.For Geoprobe/DPT or Closed Loop Geothermal Wells having the,same. .
Well Contractor Name(or well owner personally abandoning well on his/her pr 110D /D construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
3 5 A Central Off abandoned:_ /
NC Well Contractor Certification Nwnbcr 7b.Approximate volume of water remaining in wcll(s):
/ (gal.)
og! FOR WATER SUPPLY WELLS ONLY:
Company Name / / 1
2.Well Construction Permit#:� CI W ,�3 —Q ,Z 9 Z 7c.Type of disinfectant used:u n�� e rL I-Q 6
List all applicable well construction permits(r.a.UIC,county,State,Variance,etc. known G"" ,v ,.f 1
3.Well use(check well use): 7d.Amount of disinfectant used: G a
Water Supply Well:
7c.Sealing materials used(check all that apply):❑Agricultural ❑Municipal/Public Neat C _ ,
ement Grout � ,.y t ❑ gee Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 919esidential Water Supply(single) ❑ Sand Cement Grout i
�✓ o la❑Industrial/Contntercial ❑Residential Water Supply(shared) ZConcrctc Grout
❑Irri ation ❑ rill Cuttings
❑ Specialty Grout J U L 'n
Non-Water Supply Well: N oil
❑Monitoring ❑Bentonite Slurry (fl�S>Ft`ali'1 i"Iro- W4er;Mplain under 7g) '
❑Recovery �_ :T �[r1 Injection Well:
7f.For each material selected aTiov/p ovi a amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier e elf C42 kit ei^'�6 r� � O A C j'� �j.yp��
❑Aquifer Test ❑Stomtwater Drainage S ` a[ f /n
r a
[]Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g•Ptovidee a`/brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) TiI t.{'y- ` +�W / C4S•� 1 r�
r
q VC �`' >F
4.Date well w s)abandoned: 7"' 7 - /. � �3 � ``S� /W
6:0Q✓ ` ��`5 e
5a.Well locatio �
rin: !1 �C n 1
w C u l D JC7`r. i
k 7��IGo cc.
Facility/Owner Name Facility ID#(if applicable) 8.Certification: 4 S` -f ,<
t/ n !/� p��i L s
T Q B n�r �4 P r��C "'•
b Ro 4 Lv to ��0� �, k
Physical Address,City,and Zip 0 — 7 I V I,4 O.13
' Signature of Certified Well Contractor or\ II Owner
2� / /L � Date
County By signing this farm, I hereby certify that the ivell(s) was (ivere) abandoned in
Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 TVell Constrttclion Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy ofthis•record has been provided to the well owner.
(ifwcll field,one lat/long is sufficient)
0 9.Site diagram or additional well details: i
- .3 6 .46 tl 3 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 WELLS BEING ABANDONED
Attach well Construction record(s)ifavailable. For multiple ipyeclion or jton-ivalersnpplv ivells SUBMITTALINSTRUCTIONS
ONLY with the same consn•uctiaalabar+dwunettt,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion olf well
6a.Well ID#: abandonment to the following:
'/ Division of Water Resources,Information Processing Unit, j
6b.Total well depth:_ 7-D (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
i
Z 10b.For Iniection Wells: In addition to sending the form to the address Loa
Loa
6c.Borehole diameter: (in.) above, also submit one copy of this form within 30 days of completion Swell
abandonment to the following:
6d.Water level below ground surface: -7 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
fie.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form 4o the
address(es)above,also submit one copy of this form within 30 days of co llp�etion
of well abandonment to the county health department of the county here
6f.Inner casing/tubing length(if known): ft.) abandoned.
i
6g.Screen length(if known): (ft.)
Forni OW-30
North Carolina Department orEnvironmcntal Quality-Division of Watcr Resources
Revised 2-22-2016

�h
I
ROY COOPER •Governor
NC DEPARTMENT OF KODY H.KINSLEY•Secretary!
HUMANSERV AND.
HELEN WOLSTENHOLME • Interim Deputy Secretary for Health
MARK T. BENTON•Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
Lori Benfield June 20,2023
2140 Country Club Rd.
Lincolnton,NC 28092
RE: Approval No.WWIV(1650
k Abandon Well without Removal of Debris
2140 Country Club Rd.
Lincolnton,NC 28092
Dear Ms.Benfield:
On June 20,2023,the On-site Water Protection Section received your request to approve the abandonment of a
water supply well that currently has piping/plumbing inside the casing,and removal of this material is not an option.
The approval request is for the abandonment of one(1)water supply well at 2140 Country Club Rd.,Lincolnton,
NC. In your request you indicated that due to the depth of the material and uncertainties surrounding the ability to
remove the material in the well,properly abandoning this well per 2C.0100 regulations is not an option.
Based upon available information provided by the certified well contractor you are approved to abandon the well
without removing any material by pouring a cementitious grout into the portion of the.well containing the piping and
properly abandoning the remainder of the well to land surface,in conformity with the teqdirements of 15A NCAC
02C.0113. A copy of this approval should be attached to the required Well Abandonment Record(GW-30)as well
as the county well permit at such time that it is issued.
The approval of this variance doe
s not affect any of the other requirements or limitations of the Well Constru any well
ction
Standards,including but not limited to the requirements in 15A NCAC 2C.0113(b)to repair or to abandon
which acts as a source or channel for the migration of contamination or to your responsibility to comply with any
other applicable Federal,State,or local laws or regulations. Furthermore,the granting of this approval is for the
well location only,and in no way relieves the owner or agent from other requirements of the North Carolina Well
Construction Standards,or any other applicable law,rule,or regulation that may be regulated by other agencies,nor
does it imply sufficient water quality.
If you have any questions regarding this variance,please contact Wilson Mize at(919)-270-9665
Sincerely,
L ')112c cso, TT y�
Wilson Mize R.E.H.S.
I
NC DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF PUBLIC HEALTH
LOCATION:5605 Six Forks Road,Raleigh,NC 27609
MAILING ADDRESS:1642 Mail Service Center, Raleigh,NC 27699-1642
www.ncdhhs.gov • TEL:[phone] • FAx:[phone] 1 1
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

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