Lincoln_Well Abandonment_20240423

WELL ABANDONMENT RECORD 170rimtM11UsdONLl•:
This form can be used for single or ntullipte isells
1.Well Contractor infnrntation: WFLL ABANDt1RMENT DETAILS
Brian Ewing 7a vunihcroC%rdlsUcinytal►auduncd: 1
Well CndtaclorNanie.(amt-di6ivefrp6mmllyaltar:lunhiox,,tlonhidlKrprultcny) 1'w• mglapk. 0Vediar a• r,emrorri; sjgiph,. Vella ONLY wah r;,e• .,ra'tte
cYxtsfrtrcf+rkr'��utnlivu+t�++f,irir+ccursulnnrlfniraJann•
4240—B
taC Wo11 Qm1racturCaniftartion Ntniitcr 71i.Anprozim itc vulunic of water ttrn:rining in%v ell(s):
SAEDACCO FOR WATER.SUPPLI'WELI5 ONLY-
Cong+aq+Name 7e.1ype of disinfectant used:
2.Milt Construction Pertuft 0:
LW all apphrable tre11pnrtreftr(i.e.Cwrm-,Stam,J'ariarve•.L�rrlirfrr,rtc t ff 0tawa 7d.Amount of tllslnfcetant used:
3.Well oar(chccicq•eil use);
Water Supply Well: .7c.Scaling inkerials used(check al l ihiit apply):
i7Agrirnittirat otvknicipl ttblic M Ncat Cement Grout I7 Bdmonirc Chips orRllcts_
00cothcrimil( catin>acodling'Supply) 011esidentLat Water Supply(jingle) ❑Saud Ceutenl Grant ❑Dry CLty + "'
�}'� ...:�_.•c.::;" �: ;---
❑indusfriaUComnicrcial ❑Itcsidentbil Water Supply(shared) 6 Ccoewte Grout ❑Drill Cuttings •
❑irti^[iou ❑Sp cinllyGrout ❑Gravel A�� q2G24
Non-Water Suppiy Well; - _ -- ❑13amotifte Slurry ❑Other(e plainunder 7g)
291vimtiloring ❑Recover
Injection Well; X For each material selected'above,provide antottot of.tuaterials vied:
❑AgniierRecharge ❑GruttitdpalerRentedialian Neat Cem.:94lb- ,Wtr:7gal. Sand Cem:ilb ,Wtr:gal.
El Aquifer Stonige atil Recovety ❑Salinity Barrier
❑Ails fifer Test ❑Stonnwater Dmtuage
❑E\•periutemal Tct;lmologv ❑Subsidetxe Conttul 7p•Provide a brief description of the abandonment protmd."re.-
❑Geothemlal(Closed Loop) ❑Tracer
TREMIE GROAT FROM THE BOTTOM TO THE SURFACE
®Geothemiat(ficaURRICoAn Return) ©Othcr(ex lain under 7.0
d.D:fmcll(s).abandonctt: 3-25-24
5a.Well location:
Warlick's Grocery
FadlityiCtvmt Niurc Tacility 1Db(Fappli:ablc) 8.CCrtiRcatfotl:
2673 Plateau Rd. Vale, NC 28168 Brian. Evw n 4/2/2024
Pligsical Address.City.and Zip Sigtcthtn or(eitiGuW W'dl Cgntra,tar:.r r.+al Ctcn r 0a14
Lincoln Jfa.signing this fart+r;1 hereby certify that the u•ell(s)tars pgwN)ahrmrloned in
Couuty Parcel Id.mifi6tiouNo•(PIN) actvnlance With 15A SAC 02C.010r).br 2C.0200(i'ell(;'1);m1mc6ou Starrbrils
and ilrat a cnpt,of this record lags•beclr prrot'icfed to lire trell ou-mr.
Sh.I.atioide and tongitudc in d4xrceatnttnntcslsecnnds or tldcinual dcgrces:-
(ifivOl rvkl,one L•t0mig is mttr,cio4) 9.Site diagram or additional n'ell details:
You tuay we the bacl:of this page to provide additional%tell site derails or%yell
N W_ .abaudoionern deta[Is. S'ou taa}'aLxt autoclt itddiciottal pages if tteczssary.
CONSTRffiCI'iON DETAILS OF WE1,i410 i➢EINf.ABANDONED SUBAiil'PA➢.➢NSTRLTCTiONS
:llfurlr ticU cnrsUairtiarr ncnrtlrsJ if mviilablr. Fitt ir:ttlhplr rr�ziiou'ar tyro-nrrtu•aitpplr '
ue.fls ONLY tridi the svnte cwr.,ourrwtrubn,rdatrrirru,tore oar submfi curr•hrare. toa.For All Wells: Submit ibis Conn %eilhin 30 days of completion or%tell
60.Welt ID#•MW-13 abandonment to the rollo%%'in,
Division of Water-ResourcLs,Information Prucesiin-Unit,
61►.Total well depth: 45 .A, 1617 Ill:ril Setvice Centel-,RAIcFRli,NC,27699-➢617
10b.Fnr infection Wells: Li addition to sending rite foratto the address in l0a
above.also submit one copy of this forin%%ilhiu 30 days of coniptetion of iwll
6c.Borehole diameter:2 (ill.) abiau➢oraitem to the followilt-
6d.lWater[evilhcion girounc[surface: (ft.) lllivislouofWiderResources,UndergrouudinjectionContrblPrdgratu,
1636 Mail Senice Center,Rald.gh,NC 273691 1636
6e.Outer casing length(if known): (ft:) 40c.Rnr�Yatcr Sunnh &iiliectinn Wells: Its addition to sending the form to
the address(es) above, also submit one copy of this form %vithitt 30 days of
completion of AN-ell abandonment to Ihe,county health depannietu of the county
Gf.Inncrcasin;;ftubin!,;tuttKh(if laraa•u): (ft.)
%vhcro abindoncd,
l
6g.Screen length(if knon n): (ft.)
Fomi GW-30 Nonli Carolina Depumttcm of Environment m J Natural ResamTes—Division of Water Rmutecs Revised August 2013
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