Lincoln_Well Abandonment_20240423 (5)

-WELL ABANDONMENT RECORD Fai lister utl t7se(m[v:.
This faun can be used for single or mullipte tiAs
1.Wetl.Coutr lctur Information: t&F.LL ABANDONMVNT Dl TA1L.ra i
Brian Ewing . 7a.Numberofvv'elLsi being abandancili 1
1Ycll a_lkminnino well onl&Ifirpilotxnp) FOP ri+gJopM: tiferL'wr or � suppfa'. wells ONLY wide ,+1w. .sawe
MfL�lff(ChrNJ iTi'dflY�i]Ulldt�ilf lY1N CCUP.s7r�'7111r'A'Ii fS7Nil,
4240-B ( i
NC 1YcU CmliriaorCctllfcatioti Nniiibcr '71r.A)iprovinatc volume of cuter re"-fling in
SAEDACCO FOR WATER.SUPPLY WFLLS ONLY:
F .
Con>p uq Isarno 74 Type of disinfectarrt use
2.WdlCotsstruciimr.Pcrnt(t
Lt�io11 npldti+?trla.urlJpumitr(Lc!'Cwun',Stm4,d'art nti e:Lr}�c4;urz.clef if bww.t
7d.mount of&-infecfi(nfused:
�.Nell uyi(eLecich`ell usej:Water.Supply Well: 7a Scaling matcrialc:ukd(effect;all that apple):
Artgrnultitiat pMrinicipal/Pttbiid N Ncat Cement Groat i ❑Bcraoliitc Chips or Pullets
pCJcollictrn d(HcatinnJCool(no Supply) pltcsidetai,nl 1Vater Syrpply(5inglo) 17 Sand fcatem Grout I, ❑Dy Clay
❑baltis(riallCvmnutciai ORcsidcntint Wntcr Supply(stit+rcd) ❑CtiuErct�Grout I' 13 Drill Clutings
❑bri lion• b Speei dly Grout ,`l7,Grw-el
Non-Water Supple Well; d Bentor»te 5lurn d`Other(ex lain under 7g)
Monitoring ORecoveiy. i
Injection!Yell; 7 f.For caclr m;tterial sdectal'abov'e,pro4 idc amouritof.ntdterialsused:
❑AquiferlRecttarhe OGtotindq tlerRentedwiott Neat Ceni.:941b ,wtr':74al.- Sand Cem.:ib ,wtr:gal.'
DAqu(fer.Stontge atxi Recovery OS:tliirity Ranier -
❑AguiferTest' �Stonmvv[etDnthiugc .
pE�peiintetual Tzcltno[ogt OSubsidence Cotrtml. 7g,Provide a brief description of the:iUaudpnment proectlure:
OGeolhennal(Closed Loop) Mtacer
TREMI.GROUT.FROM THE BOTTOM TO THE SURFACE
1.DGeothential(Iieati2OCoolin Return) C3Other(ex- lain under 7g) .
4.Date well(s)abandoned: 3-25-24 A p R 9, S 2U�L_
5a.WeD'Incutinn:
Warlick's Grocery ur,v., ... `:er. ,•. k.
racilityi6vn4Namc railitr 1llN(ifapplicalilc) $:Cet4iRiaitan: �'`�2
. •n
2673.Plateau Rd. Vale, NC 28168 �i_ri_ n 1f1f�EI1 4/2/2024
Plr}'sical'Addtcss;Cite,aid Zip � Sires.cih�it t�f Cestil'ud tVbfl(;orucxwr t;r•r.':ll Oivcx`r Djte ,
Lincoln By sigjtitig Jltrs-fntm; 1 hereby certify that r1w u'ehfvf m,av Overe)ahandoned ire .
Couui? Par0lId.wifiGitlbuNq.(PIMj accuf1dllceit`dh1M.MC<1C0'0.0100.or2C.0200fF'e11:L'onaJrrtc(luraSlrirukartls
widdrid a copy ofdris record has h6enproovidedto liteiell Owner.'
SII.)3titude'and longitude lot dcgrccslntluutcsfscconds'or dWilu(i'degrecs: '
(iftvcll AM,orw bt/iongissadreiclA4 "9.Site diagrtnt or additionatTvdi details:
- You uiay less the back of this.paga to provide additional veal site details or well
1• W .abatidoiutrervide'tr[Is. You tua} ilsoaitacliadditionatpclgesifnecessan'..
CONSTRIICTION DFTAII S OF WELL(S)Bt INC ABANDONED SURIAMAL INSTRUCTIONS'
:trludr tic0.rorixtrue•Jiart t>!ivrdJs)!j di4ailr�Jr J•ev mrrlfiplr iatl:rtime"ar rvJn•mulu'saE;a_Ip ' '
u ells fl1VLY iritli r'aP'avmt crwr�trraclwrdraAorrvSanmcurr.it a non�rLmtt 'him" Ift Par Ali wall: Submit-Ibis fool ni[tun 30 da?S of r ompletion'of tii ll
6a tiVdllDgs -12 abandonment to tilt following;
Dicisilin of WaterRes6urcr3,Information Processing Unit,
45. I617 Dfitil Scinice Ccritcr,Ralcij(li,1QC.23697-IG17
Gb.Tatnl:vvcll depth:
30b.For Tnlecllon Wells: Lt adctitiaii to seittign tlk,fotnt.ta Lire address iu.l0a
Ge.Borehole diameter.2 (in.) above,also submit one copy of this form acilhin 30 days of comptetion of%felt
abandonment to the following-, �!
Divislou of NvalerResouires,Un6rgruund Injection Coultiol Program,
6d.Water level.belcis ground surface-.' (t•(•) I636 DI rit Scnicc Ccnter,Raleigh,KC 2709-1636
ii
Gc.Outer casing length(if lann n): Vt.) 10c.Fnr JV;itcr Sirrinh&.iniection MINg In addition(o.sending(be fontgYo
the.addresses).above.also submit tare'6P3° of this'foriu Nilhin 30 daj•s of
congitetion of vvellabandoiiment to the county.Health depanmeid of the county
6L Inner caving/tubing length(if Imawn); (ft vvhcrc aliaridonccl,
)
6g.Screen length(if lmown): - (ft)
Four M1 30 Norlb Carolina Depwancra of Pm•iroomcnt mil Natuml Resowces-Division of WatcrRooftW i Revised AK_cusr 2013
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