Lincoln_Well Abandonment_20231101

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractors Inaaformation:j�� WELL ABANDONMENT DETAILS
72.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abaLdoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
O, r wells abandoned:
NC Well Contractor Certification Ntmmber 7b.Approximate volume of water remaining in well(s): 0Lq (gal.)
FOR WATER SUPPLY WELLS ONLY:
Company Name Z 7,Type of disinfectant used: /T`r T J/
2.Well Construction Permit#:
List all applicable well construction permits rz.e.UIC.County,State,Variance,etc.)ifknowm
7d.Amount of disinfectant used: b 2
3.Well use(check well use):.
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Munic'pal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) C3Z-dential Water Supply(single) ❑ Sand Cement Grout p'5;
❑Industrial/Commercial ❑Residential Water Supply(shared) Q<cmcrete Grout ❑ Drill Cuttings
OIrrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7£For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation L /' j
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage CCt/I GJit% 1 C Dsle/� /
❑Experimental Technology ❑ rSubsidence Control "
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
4.Date well(s)abandoned: 1-o z.3 NOV 2023 ~J
5a.Well location:
Facility/Owner Name Facility M#(ifapplicable) 8.Certifi_cation:
_S1401 She rrl L J J' -JX/
a
Physical Address,City,and Zip Signature of C&fied Well ntractor r Well Owner Date
49
By signing this form, I hereby certify that the wells) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record ha s been provided to the well owner.
(ifwell 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 SUBMTTTAL INSTRUCTIONS
Attach well construction record(s)#available.For multiple injection or non-watersupply wells
ONLY with the same const;719
n/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: (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:10r t Li�(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: 1 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 1 r1 (ft,) 10c.For Water Suonly&Iniection 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): !J/L I . (ft) abandoned.
6g.Screen length(if known): n 0 (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016