Lincoln_Well Abandonment_20240423 (8)

WELL ABANDONMENT RECORD roTlmernal Use ONLY:
This form can be used for simtte or multiple-wells
1.Well Contractor Information: WELL ARANDONh1ENT Dr%TAILS
Brian Ewing 7:t vtuttbcraCytdlsheitt}tabaudancd: l
%%'ell CoUnclor Name(or l.cll awwr p-.mrmlly alunki".-uell on hisllle r property) Fm wiflopk oyeviiwr or /,otmrnfej- supply wells ONLY wale ILr .,01me
cYiP13MrtCfhkliN+AY[IrN1,t7eYlf,1CW ftUY evlNAff rNISI�]r!!I,
4240-B
NCiYd1 ConlradorCenlfGilion NnniieT 711.Approximate vrllnnte ofvvater remaining in
SAEDACCO FOR WATER sUPPI.Y WELLS ONI.N
Congran}Name 7c Trpc of disinfectant used:
2.Well Construction Perntit`f#:
Ilse m4,glph a+le uwIllarerrirs(Le_Culr h;Wm,)arlmxe.bVertiore,.efc I l fk wwa 7d.Attiouur of disinfectant used:
3.Well w (check well nu)-
Water Supply Well: .7e.Scaling nnaiteriads used(Cheek all that apply):
17Agricltltimlt 01dunicipmlrf'rtblie M N=Cement Crout ❑ pclllonite Chips or Pcncts
130mltcniull(H;:atingIC.00lino Supplpj ❑Residential Water Supph•(siunlc) El Sand Cement Grant ❑Dry CUy
❑IndustriallConinlcrcial ❑Resdential Water Supply(shared) ElCourtztc Grout ❑ Drill Cuttings:
Mitigation ❑Spec:ialp Grout ❑Gravel
Rou-WatcrSuppl}NVcIt: ❑Bentonite Slum- ❑Other(esplain under 7g)
29Mmiitorine ❑Recover•
injection Well: 7f,[or each material selceted above,provide amount of.materials used:
11AquiferRcclt3rge Mtn utlducrlerRemcdiation Neat Cem.•94lb ,Wtr•7gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Stonlge and Recovery ❑Salinity Danier
I]Aquifer Teri ❑Slonnwatcr Drainage
❑l�p:rintentnl TcLlmula�y OSubsiderKr Cortrrul 7;.Provide a brief description rif the abandonment procedure:
DUeothennal(Closed Loop) ❑Tracer
TREMI GROUT FROM THE BOTTOM TO THE SURFACE
©Geothermal(Heatinitr'Coolim Return) 130dwr(ex lain under 71t)
� �.k •R.s i l'1, •'(
4.Mite well(s).aba ndoncd: 3-25-24 pnD
5a.Wen hwation:
Warlick's Grocery
S.Cel•tification
raeiltr}'iChern:r Numc ra:.ilitg IDm(f uppliwble) '
2673 Plateau Rd. Vale, NC 28168 Brian E 'n 4/2/2024
Physical Address,Ci1}•,and Zip tiierdlnvcorCCniG;W Welt Contn.rar:,t.I,11(hen r Daw
Lincoln 13u.srgrir{g this forma 1 hemby certijt flint 11re Trellis)was(mele}ah[wdared in
l:onuly PareCl ld.ririfccitlnll No.(PlIN) oaordance wilh I i--1,CrIC 02C.0100.or 2C.0200 Mell Cvirstiaiclion StandrrrTl.
and Thal o cope oflhis record hiss been provided to lire irell owner.
Sit,t ltitude and longitude in degrccvrntivatcslsccands or decimal dcgrecs:
(lrnett rater,gibe Lvjtnng is rlt;,i¢r7) 9.Site diagram Or additional well details:
You may use the back of this page to provide additional nzll site details or well
T\ W abaudountem details. Yea na}'also altach�clditiotral pages if txcessan'_
CONSTRUC-r1ON DETAILS OF LVCIA-fS111EING ABANDONED SUBNHWAi,iNSTRUCTiONS
:tfLxlr irrll rarvlra�fiau racnr:l's1 Ij ot'ry![a!+lr. 1iv rrulaplr njectiax'rw 1J�n•irutrr wt+plp
nxlly U,VLY rrlth Ciro some,cwr,tnxnorr r!atr[hirraeru.r.+rr con n+Ltrrit cure junco 10a, For All Wells- Submit IhLS form within 30 daps of completion or tivell
Ga.Well fD#:MW-lB ibandonmcnl to the folloveing:
Division of Water Resources,Information Prove+sing Unit,
Gb.To tail depth: {ft;}
45 1617 Mail Senice Center,, Raleigli.NC 27699-1617
10h.Cor itilgT11on%Veils: -In addition to Sending the form to the address in i0a
fie.Borehole diantcier:4 (ill.) above,aLSm it subm one copy of this Conn within 30 days of completion of well
abautdomnem to the folliiwintg:
Gd.Water level bc[nn ground surface: (ft.) Division of Water Resources;Uudergrouud Lijection CottIiol'Progranl,
1636 iNIAl Senicc Center''.Raleigh,NC 27699'1636
Ge.Outer casing length(if laignu): (fG) lac,ror-Mler Sytnnh•A Lijection Welk: In addition to sending the form to
the address(es) abo%N. also Submit one copy of tiris form within 30 days of
completion of wrli abandonment to the caway health depnnntem of the county
Gf.Inner casinWtubing lenggth(if lmaw•n): (ft.) winerc❑Witdoncd,
GF,Screen length(if known):
i
Fame G11'-30 Nonh Carotlrn Depommem of Environment aryl N:uuml Resot.2cs-Division of Water RcauRs Revised Ar2ust 2013
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WELL ABANDONMENT RECORD For lnlcmalUwONLY:
This forfn can be used fir single-or multiple llAs
1,WcIl Contractor Information:' I WELL ARANDONRIENT DETAILS
Brian.Ewing Tor.vumbcrofvvit@shcin�nhanduneli 1
NalfCoamdorNimmetoreMI61vaerp�tsonally,ohanlonW;,via onl&fl,ertnapcny). RV, 011dop?a lifer'om or IVin-Imfea suprn'. walls. ONLY 'wide Me. .stmic
cmi•trtrctttu,+i�oredurni�gal;iron�Ym s+rEwi7l'a'ie_J6ru,,
4240—B
NC Well Cbnlrador,Ccnlfattiliti Nntiiict 7b.Apl�ni�imute�olmml of vsatu rel utning in%yell(s):
.SAEDA000 FOR WATE.R SUPPLY WRLLS.ONLY.
i- .
Con,pan)Name le.type of ilbinfitiunt used:
2.Well Coustraclioil Pertult.tJ:,
LwtillgVitmlleu�ellperaraw p., GIttlS7a:o,J'dr(amce.Ly'actometcl(flGwwrt 70eltrionuaufdliinfectaut"n5fY1:_ I' '
3:tYel@ uyc(eLecicvsell
Water supply Weli: 70.Scaling materia6 used(cbeci;all that apply):':
t7Agricultittat 17b1tin'icipaUf'tihlic, M Neat Ccmcnt Grout - ❑Bentokc Chips.or Pellets;
130eotlictuml(HcwinglCoplino Supply) p[taideutial Watcr Supply(single) IT Sand Cetttent Grout 13 My Clay
❑lndtisftiaVCgtnntcn ia1 ❑Etcsidenti7l�Vhter Sttpply;(�hitttd). 11,Conctele Grout i ❑Dritl Cultings
❑Ttri' tiara. p Speei, y'Gtotd gGrreel
Nan Watcr Supptr Well' - C1 BeMofute Slutry I• 13 Ciher(exTioiffunder 7g)
B9Moidiarlffg ❑Recoven'.
Injection NVcit; 7r.For each tnaterial scicOed'aboic p%tide amount of.ntatciials Mad:
❑AquifciRcctwrge OGrouiuil►tter•RellwLaiotr Neat Ceai::941b. ;Wti:7ga1. Sand Cetn::lb ,Wtr:gal.
LlilquiferSlontge afxl Recover' OS:tliidiy Darticr � '
❑Aquifer Test ❑Slomnvvter Dnthutge '
❑EVrrinteNal Tt!chuo[ogy' I7Subsldet><e Colarol, 7g•Provide a brief description of the abandonment rtt!ceonre:
❑Gecthennal(Closed Loop) ❑Tracer
TREMI'GROUT.FROWTHE BOTTOM'TO THE SURFACE
Occoikenual ffl6tiaw)Cooling Retum} ®0dler(ex lain under7g)
d.Datendt(s).abaniloncd: 3-25-24 r i..;?
APR 2{a �VeOlacation: 14
Warlick's Grocery "
S.a;ertilicatlon.
Faciliq�lCltvttbr Namc Facility]Dk(irappliwble) L':c4,;;•�Lj.J
2673 Plateau Rd..Vale, NC 28168 Brian E win. 4/2/2024
i
Physical Address.City;attd'Zip Sgegtnn orC:nirutil WVol 0Q,nt;tar qr r,'41001vwr D;ae
Lincoln 13y signing this fame l hereby certify'-tlrut the 11'ell(S)'AUT(1verr)ahemdOnerl he
t"oemiy Pwcel li4wificidmNo.(PIN) rtccmiahce itlfh I5A_*A:CAC:0.1C.0100.ur 2C.0200 Mell Cgtis'trt(ction Stdndrm7s
and that a eopvofthis record has been prtowded to 11re4vall otmcr.
5b,Latitude and longitude in drgrecslntinuteslsecandsbr dcelnrel itcgrces:
(Iry ell ft41,ow.t,16 41,is s,dreictit) 9.Site diagram or additional R'ell demIN
You tua}'use.tlie bad:of this•page to pray'idd addiliolial we'll site ddails:oi well
N W. .abauIdoiwtetudetaits..Yourua}"ai(kh'udtiitionat pages itnecessam,
CONSTR1tMION DETAlIJS AB WELLS)BEING ARANnONED SUnblt7TA1,iN.STRiiC'TTONS
:Mach murd(s)Jf dtbllrl<hl rw•urulnple rlrjriticvc;rJ tx n•utitu swpp4y {'
vrellsONLY uitG rlu svmrcwuurx((o�r aAorrtAarrr,crtl,iuu�xtn nrbm(fwrelynie laa:Nnr All Well ,Submit fh45 fame within 30 day`S"nf compaction-of uv l
Go Well ID :MW-6A "abandonment to tttz following: '
Di}i3itin of«'dterRcsuurc .Gtfom, atinn Processing Unit,
45 t617 AWiI.Scitiicc Cctitcr;Raleigh,NiC.2769J'J-1617
a Totalivelt depah: (M
' 1lOh.xnr Tnlecfivin Wells:_ LL addition to sending t1Ye fornl.;ta the addi>'sss ip'[Oa
6c.Borehole diatueter:2 (in,) above-,Also submit pnc copy of this form within 3Q days of'comptetioit bf ti-ell
abitndonntmi totla:faltovvhig_
6d.Water levcl;bclon gtnund surface:. Dil'islon of Winter Resources;Underground Injection Coulrbl Ptdgriim,
1636 Mail Scnicc Ccnfcr;ltalcigh,KC 276139 1636
Gc Outer cgaing Icn tlt(if Imuuan): (fw9 10c F—AM-iter Sttri»h'.F.iitiecrino�V Ile: Tn idditian to sending the form to
tile,addreWes) above, also submit one''copy of this form Iviihin 30 days of
coroptctipopflv,;ll nbandotttnent to the runty health depanment of the county, .
6L Inocr•easin jltubing length(if lmown)i (ft vvinn;abando.md,
6$Screen length(If Wown); (fY.)
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Fomt GN-10 Nanh Omtlm Depatumni of Environmcm mil Mutual ResotLuLs—Div isionof y ater ResowLcs Revised August 2013
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WELL ABANDONMENT RECORD rot twermlliacONLY: I �.
This,faun can be used forsingte or mtilliple tij�lls V
f-WctkCcttitractor Information: WELL ABANDONh1ENT DETAIts j
Brian Ewing 7a vtimU rr of vs_i•ils Ucin}I abandon ed:
�VeltCautratYor.Nanie(orttirllory&Yperion�llyaUastifmrhr;ecll�nhivlhnpiopcny). FN misrrpte Uftldiwr ar non-ii-N& isupi#. tells AVLY with t1,r .swore
e cwssMrcorai a5airrh>atrseRat,Iran cior sr�baatlt'cvre j6nar;
4240—B.
NC\Yell Coniraaorr cillfi lion Nini 6cr 71r.Apllmximxte%uhnne of tiat&'rein ining in tt•c11(s): (nl}
SAEDACCO FOR%%1A i ER.SUPPLY NV F,LIS ONLY: .
COS"?Na 7c.Typc'otdhjnleetanfunt;d:
2:%Vela Construction Permit 4:
ll�cllup;>tJivhlsurlllararitr(i.e.Cu;aril.&ale,J'ru1mxe:Lr'rrtian,ztc,tfJlrrmwra 7tyAftioetnroft13s1nfcCtt{tltused:
S.�Vcll usr(cbecicd•eU use): u ,
Witter Supply Well: 70.Scaling materials user((clie all that npplv):'.
❑AgricultumI piNtinicipal/P(tblic M Neat Ceaicut.Gmut j ❑Bcntonitc Chips or Pcilats
Mcollicmtal ftatinj�Cootino Supply) gltcsidcrrtial Watcr,Suppf}•(single) El Sand Cement GrantO Dn Cl y
Ofn¢tistriallCotitntctcinl ❑limidential%VntcrSuppl}•(shared) ❑Couc'teleGrout j CI MillCultinls
Muirlion ❑SpeciiltcGraul d Gravel
lion 1Vater Supply Well: ❑Bentollite 51urty i 0 Ocher(explain under 7g)
122Monitorhtg... DRecovvey 1
tajcctian Well; 7f.For each ntatcri,il selected above.,ptinidc:tmanrit df.dt:itcrials n'scd:
DAquiferRcclrarb*e. DGriittndssalcrRerrtedi lion Neat Cem.:941b. ,Wtr:7gal.. it Sand Cem.:lb ,Wtr:gal.
OAquiferStarageand Fiiowery ElSalin y Baitier
❑AgniftrTest ❑Slonmtvter.©rairia e
pExperinterual Tc bnoto4lr t]Sulasider>ra t"otdml 7K Proud.a brief description of the abandonment p.rq&vlurm
❑Geothennal(Closed Loop} OTracer
TREMI:GROUT.FROM THE BOTTOM TO THE SURFACE
J.Meothei6at(Heatingtoolin Retum) ❑Other(ex lain under 7g)
'I�,.-6��. •1��t •lei 1. :�,, '
4.Datcw•ell(s).abandonct1, 3-25-24' APR 2 'r 2024
Sa.We11:ocation:
Warlick's Grocery
FacilirypUSvn rNntrc Facilitt•1DN(irapplkablc) ti.Ccrelfication: !'
2673 Plateau. Rd. Vale, NC 28168 B_ri.a h_._E 'n 4/2/2024
Ph}sical''1dd>cs.City,and Zip' pert r Ua7e
Lincoln B),signiti this farm(;I hereby certify•r wr the sretl(s)Nits(1rele)ahruidoned in
C\iuuiy Parr:ell&n t6WjtNo.(Puv1 occnrtkittceirilltli.f XCAC.02C.01OO.'or2C.020014e11`Co;istruclionSlawkirels
and drat a cop}'ofUris record has he'eit proiiddf to the bell otfnen-
5b.I-itilude and longitude hi,degrewtotinumfuconds'or decimal degre@s
(irwell Ca IJ,ow-tiOl sta is Nit1Tt9cM)- 9.Sita diaMr,M or additional well detalls:.
Yod tuagarse.the bad:of.".page to'laravide:additioual A ell site details*&'11
N W. .abaudoiwtertidetaik,YOU ivay aISOaita'cht ddiiional pagi s if rtecessaty_.
C(INSTRIiMMN DETAIL.R(IF WELL(%BLrING ABANDONED SUBhit fTAi.iNSTRLTI'i TONS.' j
:t(frttlt u!cll cnrs'lrmefirirt tarorer�sJ!I'ai�ullra!!r. Fcv amarlaNlr h�ioolrar aann•iixrlu'sspjalp � '
urlLtOVLY with rlaa svmrrrurstrrartJotrrarmrrhxracnm,.irao rnn nrhmit,cuieh nib' 10a:Fur All Wells:' Submit this faf i%ithin 30 days-of completion of well
ML Well1Dg:MW-2 abandonment to-tho follolt'ing; .
DM4kin of Water Resini rets.Inrornwtion frocesiing Unit,
37 1617 M-01..Seitiice Center;Raleigh, 2'769'1-1617
6b.Tatalwell depth: (ft.}
(Ott.Car inlcctinn Wells. In addition io kbding-tha form to the aldiess iu:103
above,also submit and cbpy of OiS ftimt}vilhin 30 days of"completion of sell
6c.Borehole diameter:2 (in.j abindountcut te'the follanirig: "
fit.Water level below pnnntl surface:. (ft.) Division of Water Resources;Underground InjectionrConlrul Program;
I636((fail Scnicc Ccntrie,Ralcich;i1C 2769J 163G
L
Gc:Outer.casing It nih(ifl�olru): (fw) Joe.inr tYarer Sttnnlv'Rr.lnicettari��'eus: In addition to sending the form to
the addresses)abate.-also submit one copy of-this farm }Yubin 30 days of
comptetiati of.vvell abandoitmctn to the count}'health departmetd of the county
wh=abandoned,-
6f.IInneretr_vin„/tuhinp,length(if(mown): (tlt)
6$Screen length(if known): A)
Famr GAr-361" North Cami1m Depsnm:m arFnviroatawl and N:umsl nerowrCs—D1%,is[an cMatcrf{rsoa=S licti[scd Aaausi 2013
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WELL-ABAND-ONNIENT RECORD rorttttdinalUsaONLY;
This form can be used for singlz or multiple jwHs I �.
1,Well Contractor informAtion: WFLL ABANDONNIENT DETAlu.;
Brian.Ewing . 7a.DNumbcr abandon`d 1
lYclfCouuaeeorNani�(or�rillocre�pcamrally.alnsrtontri;ucll.onhisll:crprotx Few reniiupia crfecvhur .a nor:-yixu r t srrpf.* 'Melb'. 'ONLY wtdr Mw .srune
cdxtifrrrcti[Hi�erbairchuirs��rr,isuneimsaLvrUt°ansj6nn,
4240—B.
NC well Gl ntraaorC44ticailou Nmifti. 711.Apnmzi natii volume ofivaici i�initig in well(s)i (,►l)
SAEDACCO FOR WA'tF.R.SUPPLYIVF.GLSQN1.Y:
Cdrtq+anyNamc' 7e.Tygc of disinfectant used:
2.Well Construction Permit k:,
lC4 rrll,rpjrflauble u elJyerlrriLY_(1,a_.CoJrtrti;.Srv4,1'urlrrrr<e:lr�ea ern;.rlul If Grorrrt
- 7d:.li1ounl of ilL,lnfecttinc trstvl:
I`Yell stye(ehcdc�feu u+c):
Water.Suppl_v Well: Ye,Scaling rnatedwsusc_d(cbcckall That apply):
C]Agticnititrnt l hfuniCipall)�ttlYlic M Nett CcmentGtaut ❑Qcntoniic Chips or Pellets
130motlierm,•11.(140tin�rlCgalinp$apply} pitcsidctrtial Water Strppi} (single) 'd Sand.Cemr)tt Grout Q Div My
dlndu51tia1/CvtnmciCiai ❑ltesicleutial Water Supply(sliarcd)- d Concrete Grout t]Drill Cititin9S
dltti' tiou. . ❑Specialty Grout CI Gravel
Non:NVater5uppiyWdl: d BentotuteSluay 13 Oilwr(explain under 7g)
imMoriitorine ORec:ocen_ .
linjcction NYell: X Forcach material selcctcd'above,proside amoutit df-matedills deed:
OAquife01cdiarge OGtriuiuiu 11erRemeduuiau Neat Cem::941b ;Wtr:7ga1.. Sand Cem.:lb ,Wtr:gal.
Orlquifer Storage#n:l Recoi-my OSaliitit}*Battier
OAiiniferTest : OSliirnq�vter Dntttiage'
17Ea4tecinteWal Technology t]Subsideuet Cotttntl 7g Pru)Idc a brief description of thc'uiianilunmcnt pntc�ul"re-,
tDGeothetntal(Closed Loop) OTracer
TREMZ.GROUT FROM THE BOTTOM TO THE SURFACE
Meothertat(fieatina,'Cdoli Remm)_ pvlher(explain under7R) _
r. ,.6 a•
J
d.Dawelt(s).4bandolted: 3-25-24 {
tt r
{a.wentuei6n: .
- I.
Warlick's Grocery
$.CetllRcaflou: tire:
FaciliglUtcncr Nmrtc Fa:.ili>r•]jaA(rappliwblc) G.i t.�i�_•�v
2673.Plateau Rd..Vale, NC 28168 B_ria n_' Ewi n 4/2/2024
'' .
Plt}'sical'Addms;City,and zip sigytjtnrd fir Ceitirw%V61101al or:,r r.'Al Civrur Dare
Lincoln. 1iy signing this farnr,1 hereby cerdA.-lane the u•e11(r).wins(irere)'uhandoried,hr
Cottniy Panel ld.,W116ciUnallo.pwj •accurdance With lief.V Ad 020,0100,irr 2C.0240 rre11'6uristiatcliun Swackirrls
and tlrrrt a coPy ofibis record Im been provided to Ilre well otmer,
Sb.•I.ttitude and blA&de In degmesWitutafscirtntis or dccinl ol'ilcgt Best
tir«ru GW,ow Lithons is!9.103etcni) 9.Site diagram or additional well desalts:.
`You.iva}use.tlie bad:of&6.pdge to"*r idd:addiiit tlal well site details;or well
N •abaudomneattle'lails.,You way atsciztach:iddilioual pdges if necessary__
CONSTRItMON DFTA1L.ti OFWEiiL'fg)IWINGABANDONFD SURM1ii7I717AL iNSTRLTC vox,-%.
ttfrxh urll wrirUuctiatrt rn'mrdl;}lj u�roflri?li hlvv multiple iujecdo"'ar mn-nwtir suppfp '
urnsUaYt1 ntOrelansvmrxrursourrraau'rrSmuMrr:cnrt.��ucannrbmiiwrr »r� 10a.Nor All WeN Subtnit-this form icitltin 3o diiys of conjplction of WC11
abandonment 1o'thc folloiAn
Division of►Vater Resoureft,lnfocmation PrPeL.Niiog Unit,
37 1617 Mail Scn•iee Cetiter,'Rakigh,XC 27699-1.617
6b.Totativell dep4h. - (R:)
Ibb.);or inleellon wells: 'h1 additiaii to seodirig the fornt to the address[u'IOa
above.also subutit one cop}•of this fort Ntihiil 3O'4,k of completion of well
6c.Borehole diameter.2 (in.) 2bandtimrtcid to Lite follatring:
uti6dvrfacc .)
Divistou of Water Resourimi Und rgmtid injection Conitb[Prdgram
frd.Watcrtevcl.bdov� ,
1636111ait ScrYicc Ccntcr;'R41ci;,h,NC 2;
(ft 6104636
t
6c Outer.caUnR lcn th(if ImpYYn): (fL) 10c Fnr•XY-kEr Strrinh•&-fidectfon.Wc11s: In addition-to sending the fort to
the.address(es)_aboye. also submit one copy of this,form within 30 days of
completior of well abandonment to the co*y health dep:kintent of the couw
6f.Innereasin:Utnhing lenjlth(rf Imotrn): (ft:) Yvltcro atmttdoncd,
I .
fit.Soren length(if Imoan): (ft.)
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Foim G1�r-30 Nonli Carotltn Depattm to afEnrironotcnt and Nartaal Resottsecs—I?1t Isinn of PlarLrRcsowms •RMsed Att,eusc 2013

WELL ABAND.ONNIENT-RECORD For lnlcrnalUwONLY:
Tills form can be Used for single'ar multiple vviells
1,Wca Contractor Information: ArLL ARANDQNhILNT DI;TAIt_S
l
Brian.Ewing . TsL Numberofivd1sbcinl;ahandancI1 '1
\Yr]CCodtaefor.Natnc.(or�iellowouNcaas>all}'al�nJdNnexoll on ldvthrrprdpcn�) Few nildapl., 11yert;ae .or rou-1:ti&-'sirl". hells ONLY . with tb sariie
. i?+asrrtati,w;.a''oirdiu:xa,�:f,iuncw•sut4iUt'��we.�orui.
4240—B.
NC1A10 CbritraderCrrld6don Niniiici
7b.Arprnsimntc rolnlac of vFat�v'rti ri iinin in cvcu(s);:
SAEDACCO FOR%YATE,R.SUPPLV NVLL1 S 0NI.V: .
COntpart)Name 7c.Typy of disinfectant used:
2:%Veit Construction Permit N:,
4'r nil apldlcnble utWprjmAv Otto.Cu::rrR;Sua'e,Yarlatne;.h fecarm,etc:.!tf�tswwa 7d.tlitionnl of dlSinfeetdt[t'lLscil: .
3:Well Usti(ehedcirell nse):
Waters"pplti•Wells 7a Scaling inatcriuls nscd(chcctfall,that appl})p` . .
Q,fgricultutal p)ti9tinicip tbPtlblra 01 Ncat Cement Grobt G7 Bcnionitc Chips orFtllcts-
17Gcothcrm'd(HCatinglCoolitio supply) '❑[tcsidctuint WatcrSuplib-(single) 13 Sartd'CMut m Grout - -❑Dzy Cloy
pindrislriallCotirmcrcial ORcsident(at 1Vntcr Supply:(shirred) 13 Con&e1e Gtoul O Drill Cuttings
❑Irri •tion - ❑Spectiutlp Grout 13 Grdvel
Non-Water Supply.Well. 0 Bentouire Shiny Cl Olher(ex-plaiu under 7g)
Q9Montlorine 131tecovety
" Injection Well 7f:For'eaeb ttlat�ri:d sdccted'abo�c,ptx►vidc amount of.riltiteiials need:
OA'quifcrRccharLi6 pGroundn,uer.Rentetiinlio�r Neat Cem.:941b ,Wtr:7gal. I' Sand Cem.:lb ,Wtr:gal.
[]Aquifer Stomgq and Rcco1•en' l7Salinity Darrier
j
OAgni[e'r Tcst OStornvater D'tahiagr
pEglerinterital Techuotoev OSubsidettct Catttcnl• 79,provides brief'description of thc,abandonment procedure:
13Geothennat(Closed Loop) - [!Tracer
TREMI,GROUT FROM THE BOTTOM TO THE SURFACE-
©Geothermal(ti6fing!Coolill Return) ®Other(ea lain under 7R)
. .•cam=1T��(' -
a.DaievF•ct W.unandoncd: 3-25-24
Sa,Well location:
Warlick's Grocery Ue,-X-
Facilit}lUtcncrNmRe Facilit ID4(16ppli:-ab1c)
8:CcrtiRcatimt; LlrtJ.:t
2673 Plateau Rd..Vale, NC,28168 B ri: _.Eli n y 4/2/2024
Physical Ad&cm,City,and tip• ftr4low orCeitifiiiti W411 Conxticwr:,r r'411 Qwtur D,uc
Lincoln fly.signlr{g This prm;I hemby cerri• i that,the irell(s)wov(went)ahandoned in
Count) ftM I&Wbi l ouNo.(PIN) accvrrlirieic h'ilk l i(_�C�IC"f12C.pIQa.rir 2C:03a[?T[Tell'Carsdntction Stawkwds
" artdfini(acopyofllzis record hasbeeuprovidcrlto7lieu•ellowner
Sb.,I.atitttdc and longitude in di�mccslnttoittealscconds or dccinuil degtrxsi" .
(if Well rww,01k Uuilung is omitted) 9.Site diagram or additional well derails:
Youluiap itse.tl)'s ba&of this page to"prottide_additional iitid S6 deloils:or'v1•ell
.abatldoimtem'details..You may also attaeh ud{titionat pages if nacessaryy_
CONSTR1tC"rit7N nnC iL5 O WV LLM HEINC AD;'1<Nh0N19D SUBbiriTAi.INSTRUCTIONS I:
:lltrxh�irll.ewrv)ryrliore rroard(s)if For"Whipie iigeciltvf a Mfi.11w rsupply I
mils ONLY with Me uiiu7u.i urn rnn y�Lniit.aeerirm 10a For All Wetk: Submit this fort atititin 30 dayri of completion of nrll
'abandonment to the following;
6a.Wc11ID�sMW-g
Division of Water Rcsourccti.lurormation-Promsing Unit,.
6b.Total:vtcll dcplh: 47
1617 31ail SeMce Center,Italci�ti NC 2?699=1617
10b.h0r inlcctlan Wc11s: :In addition to sendiug the fonu,to the addii:ss In-l0a
6e.Borcttolo diameter.2 (in.) abotk,Also submit or16 col",of this.forin%idiiii 30 duys of comptetioii of well
ubnodonnlcru to t11e follouing:
6tR Water leccl.bctow ground surtaecd. (ft.) Dirisian of Watcr Rcsourcvs;Underg'tiiand hijecdon Control Program,
1636 Mail Scnicc Ccntcr,Ralcig6,KC,27699-163fi
6e.(Outer casing lcnglh(if L wn): Oft:) 10c For Water Surinh•Ii)nieetinn Welly: In addifion to sending ilia font to
the addresses)abote, also submit one copy of this firm Within 30-days of
eomptctioo_of nail abairetoamonr to the county Itwltk deptinnmrd of the county
6C Inner ursin rthing Icnjvth(if tarnwn): (EY)
where abandoned..
6g.Screen length(If known); Ott)
Form GW-30 North Carutim Dcpsrtmcm ofPnviroomcnl mvl Nauml Resoteres—Divislan of W.9wrResoum.s Revised Aupa 20 t1
i ,
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