Lincoln_Well Abandonment_20240423 (9)

WELL ABANDONMENT RECORD rarliftn-mlusdONLY;
This foim can be used focsineie or multiple trells
1.Well Contractor litforulatio-M, MLL ABANDClNhIt N T DETAILS
Brian.Ewing . lit.iNumberpfivdsbiwl;abundanell:'1
lYcllCouyaetor.Naurc.{or tarltifnu pcagrially 11i 1u i$rdrig tea 11 on hislllcr piupcny). hw Mlrlhple hVi'eUM ar mm-Timer !sul", walls ONLY wrrh Mv-.stole
• corrirrrrerirar•i�tiinhurrs,�rrr,ivhceursarhinlr%�.fonn,
4240-e
NE Wcq CbntradorCanifiGllioti NtniiScr 71t.Arprnzitnatt rnlumt of tbulir rtiitainin8 in�t•ell(.r•};_ (pul,)
SAEDACCO FOR WATffRSUPPLYWE?L[S ONLY:'
Qrmpatq Name 7e.Typeiif disiurixtant used-
2AVellConstructiou Permit q:, ,
L[tTpUnppfli,lhle will
Perto&q.acCvjr*-, cti,l'urjam.hr,1 tinm„ek;)ybwwn 7dxtnlountuftliSinfectsiut'used.
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3.Nell use(check hell use):
Water Supply WeIL X 861hiig materials;uscd(clicd•"ali Neat apply-):.:
DAgta:ultiliak DMtinicipab'Yttblic. dE Ncat Ccnicnt.Gtout 13 Mmonitc Chips orpcllcts
0,,0G0111=31,(Hc;ttitt*Cooliti,,Supply) 171tcsidot1tial WatCr Supply(single) "D Sanclfientew Gtuut ; 17 Dry CLty
OlndiisttiallCommczCial. Mei idcutiaf%Ynter Supply:(sliamd), &ncrcte Gtout t7 Dtill'Cuttings
❑Inigion. 11 Spectialn•Graut i'' ❑Gruel
Nan Watcr Suppla W.cll: -17-Bemot»te Slutly ®Other(esplaiaunder 7g)
I9MmiilorLtg. ❑Recover►'.
Injection Well; 7f.For each.uiatcr htl scicctcd'aboye,pno,�idc amount of.Auiteiials n§cd:
DAquiferl$cha>ge. . . OGiouttdtitalCrRenteiiialion Neat Cem.:941b. ;Wtr:7gal.. i : Sand Cem.ilb ,Wtr:gal.
DAquifar Storage art l ltecov eri OSalinih•Datrier
OAguifeiTesi OStonmtvterDmiiiagd .
r .
[]Eipetitnetitrtl Taclmatoe_v pSubsidetxe Cottirol, 7; Feit�ide a hricf ticScriptian of tlic abaadnnmcnt procivlum:
❑Geothermal(Closed Loop) OTtacer
TREMI.GROUT,FROM THE BOTTOM,TO THE SURFACE
®Geothermal( eafinl Cooiinj Rehtm) ®Odter(explain under 7g)
J.Date tseli(s).abandoned: 3725-24 4 ....•1 .i ``•.f',^:1.�,', .
5m.WeD:loeatlon: 2024 .
Warlick's.Grocery {Tr`i: IC;["i; r r•-,^.�:,�.>
8.Ceaittcatioit: Ui.;1i
racilit?/UtvacrNmne racllity ll m(ira pliable)
2673. Plateau Rd..Vale, NC 28168 Bri an,E wing 4/2/2024
Pln�sicalAddrc id ss•Gity,dtZip' - Si�haocif(;criir'>tK1\b'ellGtruiattor:;r•r.';tl,(hrr}r Dal¢
Lincoln Ny sigrring 1/1. fib)-m,1 lierrby rnrNfy Mai the trellp)wets(here)abrtodoned-in
Cauuty Parrclldawrbf ojt No.(PINj wormlrncw with MA-NVAC-02C.0100.br2CA200Ifell.`Cotis'IrtleriunStdnekir[1s
acid tlriit acop,aftltls record hr vbeeio providccl to life Ivelt on»er.
Sh.)<.atihtdc and longitude lm degreevfmtttutoslscinnds ar dcciin;tl d egreesc
<If..ictl Crild,ow 1;-10 jig iSe'rtlliciCry) �.$liC diagram ar additional R'Cll dCLM1ii9:
You ma}•usetlie•bacl:of tl►is page to pdaivide.additional�itili site details,or t4ell
A' �V .ab uidomunettt-tletailS..You may also attach additional pages if ttecessaty_
CONSTRUC ION DFTAILS ORWELL(S)BONG ABANDONED SUBMiTT,U.iNSTRUCTfOYS-
Jfkwh tr¢iL-almk rdma racrud(s)if.2voW-14 .Re r Mrtlhple iiyecrimr'or riJn-un.er su1•Po'
melh ONLY lrltfi tJ,,�snmrewuirraer)wdaM1mr[humrrvu.lcnr can nrhmir curt fq'nra Mai Par ell`Wellc: Submit-tUs form itithin 30 d.v5 of completion tit.well
well
WcU IDfI.MW-7A atiandonmcnt to'thc following:
Dlgisinn of WaterResourcei.Information Proc�wtiiol;Unit,
40. 1617 Am!SejMcc t6tcr,Ra1dVii,NC 276994617
6b.Tatal ttell depth: (ft)
lob.Far_inlecolon Wells: Iu additicii to seWing t1K fomr to ihi-addiesi ln•IOa
2 abom atso subudt one copy of this form ttilhw 30 days of completion of bell
6e.Bereliole diam r:ete (in.j
obaudomttend to the follomiug:
fid.Water lent below Sround Surface. DMSlon of Water:Resouries,Und Irgiaund injection"Conl6tPr6gram.
1636 Mail Smicc Center;ItAlcigh,NC 27699-1636
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6C.Outer casing length(if hmew a): (fG) 10c rnr Witcr Surinls'.Cc iidecfion R'v 11c; tn,addirion to sending the form to
the,address(es) above.-'ago submit omejrcapy of this fomr iflihin 30 days of,
completioti-of tscd abandoiunent to the county health dcplirimetd of the coutgy
6f.Inner eminl/tubing tenl'th(if ldtau•n): (ft.) tvltrrc at>tndorecd..
6g.Sum length(if Mown):
Faml Mr=30. Nonh Carollm Depmui:ul off-sviroomc it mil Nilttaal Resources- ll viscd Av"20 B
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