Lincoln_Well Abandonment_20240119

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'.*'T ` :� , WELL ABANDONMENT RECORD
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`, 9North Carolina Department of Environment and Natural Resources-Division of Water Quality
'` 2656-A
= :<%� WELL CONTRACTOR CERTIFICATION#
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1.WELL CONTRACTOR: 5. WELL DETAILS: '
To n �}a v i 3 a.Total Depth: i 0 ft. Diameter: in. '
Well Contractor Individual 13atne b.Water Level(Below Measuring Point):- R.
( ) 44
Measuring point is ; , ft.above land surface.
Davis v 11 Bering I
Well Contractor Company ammo
STREET ADDRESS1481 Larry Davis RRd. •. 6. CASING: Ad
Diameter
Tawndaler NC 28090 a Casing Depth(if!amown):I Ad f: b r
City or Town State„ _Zip Code b.Casing Removed: ft,
( 704)- 276-3434 . . .. . , . j
Area code-Phone number _ • 7. DISINFECTION: I.
• e. •
2.WELL INFORMATION: . • (Amount of 65e%a75%ceiclvni hypochiorito used), ..:•.
SITE WELLID 4(if applicable) 8. SEALING MATERIAL:.1' '
STATE WELL PERMIT 4(If applicabe) ' Neat Cement • 1 • Sand Cement
1,3 .- OS 04eC Cement lb _Cement^T_lb. ,
COUNTY WELL P IT>r I (if app tcable) ! 'Water gil::.'it--, Water_' •�d� It al_
Q., ,"iL..__ .. F
DWQor OTHER PERMIT 4(if applicable) Bentonite JAN 1 9 2024
WELL USE(Check applicable use): gh Monitoring ❑Residential; Bentonite 1lb.
rl Municipal/Public ❑ Industriab'Commercinl • ❑ Agricuftu`ral Type:❑Slurry ' 171b1�"'�"`G�•��,.;�t,�--„JO
Water i.gal.
❑ Recovery 0 Injection 0 Irrigation . • •
. Other
0 Other(list use)
Type material �� `_ .1 t- eAir
.. • •. .
3,WELL LOVAATT�I,,O��N::��11 Amount - 1 L. •:- :u
4k
•
COUNTY4'1i14 f QUADRANGLENAME_ . • ' • ' . 1 •
NEAREST TOWN: "bid * 9, E F,XPLAIN METHOD O E 'LACE ENT •F MATERIAL:
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(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) Ian
, co' 7
m
TOPOGRAPHIC/LAND SE NO: ' �y r
0 Slope ❑Valley at ❑Ridi;e El Other 9rJ t C �
(Check appropriate setting) Ace
10. WELL DIAGRAM:Draw a get ed sketch of the well on the back of this
•
�}— May ve in den ees, form showing total depth,'depth and diameter of screens(if any)remaining
LATITUD r a 'V minutes,seconds,or in a in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE 7.1125A
" decimal format types of fill materials used! . .
•
Latitude/longitude source: h'ea/❑Topographic map j.
(Location of well must be shown on a USGS sopo map and ei
11. DATE WELL ABANDONED /a+ ��e'
attached to this form if not using CPS) ` �'
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is ideated:Complete 4a and4b. WITH 1 5A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a:complete 4b,well owner information only.) • THIS RECO D HAS BEEN PROVIDED TO 7l•IE WELL OWNER.
FACILITY ID 4(if applicable) it /O• DA E43
NAME OF FACILITY g NATURE OF C IFiED WELL ONTRACTOR DATE
STREET ADDRESS • . . :
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL• DATE
City or Town State • Zip Code (The private well owner must bean Individual'who personally abandons his/her residential well
4b.CONTACT PERSON/VVELL OWNER: in accordance with ISA NCAC 2C.01 Is.)
NAME e.. 0 ,,,. '.Tony R . Davis
PRINTED NAM EOF PERSON ABANDONING THE WELL
STREET ADDRESS t i '
•GLt G I i
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. 1, Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06
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