Lincoln_Well Abandonment_20240423 (4)

AVELL ABANDONMENT RECORD. rot uttrr>ti,l u�ONLY:
Thus faim eaa be used for single or multiple 1%�11s I
1.Welt Contractor Itrfortuation: ALL ABANDONMENT DETAIL.4
i
Brian Ewing 7i1.Number of ivells being abandoned: 1
S1e]CCoufrseforNsnie Orilcun,ra� rsgr,all tliandor,tti�acll.onMilkI i is Fey rrmlapk P+feet(rur. -iv renu-,it,ter •strpph- well: ONLY Wtl+ tlee..sraue
1 P� S' o pol,tty) i
• cmis7trcfirat�abmrrhrituaraat yrincmrsvhinif'wnfonit;
4240-B ;. I
NC 1101 Obihi cierCdnif=dot1 N,nrbcr . 711.Alipt4.0 mat6 volume of watw ietimining in srell(s): (gut j. _
SAEDACCO FOR WATER.SUPPLY WB1.L5 ONLY.,
6n,pmq Name 7c Tyllc"of ilI infictaat used:
2.Welt Construction Permit 0,, 1
EisirJl nitl><:ivhl�,uefl}cririt.(i ct,wtuv,Sax g l'drja e,brfech'na„etc)ffGrown 7d.eltnontiCaf dlslnfectiint'Ukyl:
3.Wet!use.(ehomell use):
Water.Supply Weil., 7c.Scaling tnatorials:Osed(check all that ipph•):
17rtgricnititral pMttnicip dtPtablic l8 Neat C6wat.Grout. } ❑Hcuuonitc Cliips orPcllets
AGcothmnat(Hcatinc,JCaolitig$apply9 : 'E311 dmthd Water Supply(singlcj 17 5atuffien>ew Grant i' ,❑My Cl ty
❑Ittrtdstrial(Cnti,ntcrCiaV ❑ltesidenthd Water Supply'(.oihnrod) ..17 Criucreli Grote I 13 Drill Cuttings
❑itti [ion _ 17 Speeiolty Grout ❑Gravel
Non Watcr Supply Well: - 0 Bentotute Slurry ❑Other(explain under 7g)
99Monitorine. ❑}teco%en .
Injcctian Wclt: 7F For each tuaterial setcctcd above,pro ide arnoutot of.nlatMOIStr'sed;
❑Agniferltccltarge ❑Gr6tmdit.nerltrnterliiilion _ Neat Cem.:941b. ,Wtr:7gal. Sand Cem.:lb ,Wtr:gal.
L]Aquifer Stonige attd Recoven' t]S.ditdtr Barrier
ElAgoifer Test ❑Stonnii ester Drainage
pE*rititerual Teclruotogv. pSubsidetxe CorAn,l, 7r,Pntvidea brlif description df tire,abandonment pmceldum:
❑Geothennal(Closet€Loop) ❑Tracer
TRENII GROUT.FROM THE BOTTOM TO THE SURFACE
IjGeothemtal(li>wntiRyJCooii Mum) 170ther(ea lainunder7 ) _
6
d.Date nclt(s).abandoncd: 3-25-24 Q P R 2 i' �f •�y'.
Sa.Weil location: '
Warlick's.Grocery ', ;: 4ir.x
raclitylQ Vmr Nome rmility IDtr 6rupplicablc) 8.Cerlifit:iliaii; ' fl r �v9
2673. Plateau Rd..Vale, NC.28T68 B rI a n _EwI 4/2/2024
Plr}•sical Address.City.and zip s«tnt,ict iirt cilirxil 1Yefl Caatstslirr:,r r,'.tl�sp¢r D pL
. I.incola llyr sigiuer3 flaisArm. l hereby certify that the rrell(s)was orere)abaridoned•in
cauuiv r-wrcl ld.,wirtcidnn No.(PNj acmilrrnce n9vr'l i.L:N,CAC''O.'C,OIOO.iir 2C.0200 IMell'06 isdntcliun Stdrukirels
vmd ifiat a copt�oflhis record im•be"eit pirnidcd to the well otsrier.
Sti.1 Latitude and longitude In degrceslntinutsslseco.nds or decimaldegrecst
(u I
#01 rvkl,o+a l:oltoug is s,ttrektii 9.Site diagram or additionalvt•ell details-
You'u4j use Ilse bath of'th►is.page to provide'addilional wall site ddiils'oi Well -
N ,abandoimtent'detoils..You may also atloelt arhditional pages if ttec:essaw.
CONSTRUCTION DETAILS Or ILELLM BEING ABANDONED SUBMWAL INSTRUCTIONS,
:trradt iW1 ror,•trucridu ntvrd,$)if ri.w1dri . -Fw'uruldple h1jeetirui or rstn.azrlrr supply
u1elk ONLY rrldi dx Carl m1kiii eure,r+unrt 10u.For All IVeLLc: Submit thbi form o itldn 30 days of 6nipletian oft ell
&L Well)D#:MW-2A abandonment to rho falloiv�ing;
. I
- Division of 11'utcr Rcsoure��s,Information Prncr�iny;Unit,
95 1617 Mail Scitiice-Ce6tcci INIcilth nC'2769-1617
6b.Total ivell depth: (ft.}
Ob.Tor Inlecilon Wells; In aditiliou to sending the fonu to the addiess in l0a
(lu.}
aboiv.also'subnd(one topy of ibis fonu%villain-30 days of completion of well
6c,Borehole dL•rntcter.2
abimdomtteirt to rite following: .
3i%is[onoflYntcrResoure s,•Undergrouud lfije ctfoll onlrul•PW.ram,6d, Vatcrlccibctowg nundsurtaccd. ft.) legacrvccener; ah;NC27699-1636 6r-Outcr casing length(if lmovrn)Lt (ft) 10 C rho Writer Struts&-inierttan 1I IA: In addition to_kriding the form to
tire.address(es) above. also Submit one copy of this fonu}cilbin 30 days of
comptetiori of%cell abandoinnent to the,coimly health department of the county
6L Inner usinWtubing length(if totown): (tY,) %%'hero atnardoracd,.
6$Screen length(if laiown): A)
Fora GN•30 Non4 Catullrn 1}clnnnxm of Environotent:,ni Nit[tuoi Resort.2cs-Dlvtt[an of Platcrlt�owns Revised Ate 2013