Lincoln_Well Abandonment_20240423 (10)

WELL ABANDONMENT RECORD
' For hncmll Usz ONLY:
TWs feim can be nwd for single or raWtiple iitHs If
1.Well ContmeOr Informati"M �=Llj ARANDONh1PNT DETAiLS t
Brian Ewing 7a.N mberofivillsbeingabandonedi
weltffeutm torMmic(orurLlu�sacrpz¢gnallyat>a�tonlrioxLllunhiaftIir111011 ty) pa +rarinph" .trfeer(ar ur ewer-nWe 4suppl}• -wells' ONLY with Ike sore
cY,r►tfnrcfrtui/rrbdrrc6Ninr�wrt�rrn imr mhriarkuiejbrvf.
4240-B' .
NC'Wet]Ct�nfsiaorCenlficaliori Nnm(rcr 71t.Anptn imdtc�olnnee q£vratia Hitt ti rinR in irell(a) { d)
J
SAEDACCO FOR WATF.R.SUPPLYWE.LL5 UMX.
Con+pau}•Name 7aT�tit¢nPdisinfi'etairtriseil: i� 1• •
2.Well Construction Permit a:,
Ltstcrllop;>liv&learlllxrrritr(La C ern;Stzti.)'urlaxe.Ixjectinu„rlcliflmrrsrr . 7d.elmonutofdisinfectantukxk I'
3.Nell use(chcClivYell use):. ",
Water Supply Well:. - "7&ScAliog matedibi used(chcr[:all lii t apply):•
i Agticaltitial M Neat Ccmcut Gttutt. ®BdrRonitc Chips or pellms,
I7Geotherm:d(lleating/C:ooling'Suppty) Olicsidtntial Water Suppb'(single) _Sand.Cerncnt Grout i ❑Dty Clay
❑btdtisttiallCottuttcrei tl 171tesidential Water Suppb•"(sliardd) l]Concrete Grout O Da Cutting,'
❑Uri tion f7 Specialtp'Gtout b Gravel
Non-Water Suppl}•.Well: 0 Bentonite Slurry i ❑Other(explain under 7g)
Fg}Nonitorine_. DRecoeen
Injection Wcllq 7f.for each rnaterfial selccted'aboFr;piny ids hntoanttif:ntiiteriats nycd:
OAquiferRbaltar4 , I7Groundu�terReutediiilinn Neat-Cem::94lb ,Wtr:7gal., Sand Cem.:lb ,Wtr:gal. '
t7AquiferStoctgc ato Recovery 138:diuity Oarricr
OAgnifet Test OStnrnnwter Drtiicige
t7Eyrotintentul Technology " l7Subsidetxw,Coiantl 7g,provide a brief desid tion of-th Aiandpnment prod-duce:
riGeoiberinal(Closed Loop) Innacer.
TREMI.GROUT,FROM.THE BOTTOM.TO THE SURFACE
®Geathehnal 016finiWooll Moro) ®Otherf� lain.under 7 ) .
e-r
d.'Datewelt(s).abandoned: 3-25-24
5a.Well lueation; APR 2
Warlick's Grocery ;
li.Cet9ifir7itiou: Ire:;;,';
Facilit!UivmrNi itv Fa ility IN ira Irabic
2673 Plateau Rd.•Vale, NC.28166 �. EI n 4/2/2024'
Physical-Addre§.Ciiy.audZip - $i hucorCcriiCKvlWenCoruracrnr:,r�'.tlUrtir>Lr Date
Lincoln By,signing 11us•fain; l bereby certify that the vre11(s)ir•er 6rpv)ahrmdated ire
Cannty fuel Idaraifipllitallo.(PN)' wxVn1dhce with l iA VAC 02C•01Od.or 2C.0200 itruff:Quittructian Slimiki►ds
and tbiit a clop}roffids record bay been pimided io 7&e bell Eimer:
Sri.I acitude and longitttttc in dcl w9*1minutcs1s=nds ordecimai-Lacgrcesa
(IrWelt fold,ow 1 th1 llg is S100.*1i) 9.Site diagram or additional well details:;
-You Hla tSe the ba&,of this page to'p'ro0de additional%wil site details or iscll
N �v' abatidoimtea de aik,You cony also vtach nddfiional pates ifttccr sc arv_.
CONSTRUCTION DE:TAIIS OF WELL(S)BLrING.ABANDONED StTBMtjTAi,tNBTRtfC IOY3
:tlfotlr h.cl!cvrrtrurilurt rrcw�lFs?if rirKallm4li. Fed muhfpfe htJecrlUrf ar rx�n.nnru•supply '
rrrld UNLYrrlUirl�srmrecwiocxliorv'ariaedlornncrH:_iv�urnnhrbmfecurefunir t0a:Mnr-All %Vdkv Submit-tUr,forth within 30 da?s of.colripletion of Hell
6s Well IDiMW-7 abandonrncni to the following:
�.
DiYhion of Naterltesaurce�.,Information Ptoc�iing Unit,
} 1617 AlAil Seiyicc Center,Raldgh,XC 27699-1617
6b. etal:vrelldepth q 0: (ft.
0h.For Now Ion Wctls: :In addition to sending the form to the addr>ess.16 103
frc.Borehole diarttctcr 2 in: above,also subinh one bapy of this faint within 30 days of'cotoptetion of well
( ) abirndorwrenl toile following:
6d.Water level below ground surface: (ft.) Divistoti of Wnlcr Resoureesi Undcrgriiuitd lii jectton Conirul Prro'gratu.
t G36 Dlail Service Center,li416A,NC 276994636
I
Gc Qutcr casing ten lh(if loion"n)�' (ft:) 10c ar Water SPodlih•A Iiiieerion Mills. In addition to sending the form to
the,addresses} abovi6. also submit bneicapy of this tbtnt within 30 fts of
comptetion of weir abm doinnent to tire-rouru}'health dcpaamerd of the connt r
6f.Inner cavin ftnbing lrn}gth(if hionn): (ft.) vc1'crc abdutian¢d•. 1
.I
6ti Seiren length(if 60%1a); (ft)
I
Foinr G1V-30 Nonli Carotin Mparlmw ofEnviromuent mrd Ninumt Resouoces-131rislan of Water Resources 'Revised A"2011
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WELL ABANDONMENT RECORD rot ImcmiltlsoONLY;
This fohn can be used for single or mullipte m-Ols
I.Wct1 Contractor Information: WELL ABANDONM1iENT DFTAII.S
t
Brian Ewing 7a.Number of ivells being abanduueil: 1
%V 11 Corm-actor Nook(or well mvllcr Nisarmlly ahandanbig well an hlsfllef propcny) }rw' rrnrleph hVeeutor or ww-wiper alrp)!h' wells ONLY u rib 1h .,rune
tYM1'71rChtN!•!iL'471Pitw11.'1LRlf lYlr!rilrP B;Jlulrlr rMI��J4rP1Jl
4240-B
NCAVcll Conlmoor Ceti l4cation Nmibut 71r.Approximate volume of water remaining in
SAEDACCO FOR NVA'fFit.SUPPLYiNFI.LS
Can+panq Name 7c.Type of disinfectant used:
2.Well Cousttuclion Permit N.
Lit ull ulrJllrab�•well}nrJrrila(i.e.Cr.MN,Shae,;'arJiJ we.htJerhoff,elc}ff,bwwfj 7(L ARLOIInt Of disinfectant used:
3.Well usr(chcek-well use):
Water.Sitppkv Well: 7c,SC;tliag m;itcriids Ilsed(cliccic all that apply):
❑Agritnitttta[ ❑hlttnicip 11Ptlblic W Neat Cement Grout U Hemonitc Chips or Pellcts
13C)c0tltcrrwt(t3citingX001ing Supply) ❑ltcsidcntint Watcr Sirpph•(.jingle) O Satin Cenienl Grout ❑Dry CLry
❑lndustrial(Conmtetcial ❑Residertinl Water Supply.(simcd) O Concrete Grout ❑Drill Ctulings
L7litig tion O Specialty Grout O Grreel
Non-WaterSupplrWell- tJ BenloniteSlurty O Other(explain under 7g)
1291Nonitoring ORtx:oven'
injection Well: X For each material selected abotc,pro%ride antotant of-materials used:
❑AquiferRecltarge 00lomid%%-Ji rRellteiliasion Neat Cem.:941b ,Wtr:7gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage aids Recovm, ❑S linty Danicr
❑Aquifer Test' OSlorinuater Drainage
1313--xWtitnerual Teehnologv ❑Subsidely a Corilprl 7„,Provide a brief description of the abandomncnt promduret
Meoiliennal(Closed Loop) OTracer
®Gcothenital(Iieittini;lCoolinF Return) ©Other(explain under 7lt) TREMI GROUT FROM THE BOTTOM TO THE SURFACE
4.Dattwell(s).aWndonat: 3-25-24 3 t
:a.Weil location:
Warlick's Grocery lT,`e. :�•-- .qr., :
Facilit-irhtra:rNatw rmillyIDS ira licabicy R.Ccrtlficttioll: a
y ( PP Min
j p�
2673 Plateau Rd. Vale, NC 28168 Brian Ein 4/2/2024
Pltv si al Address.City,gird Zip Siilhrre nr C esliliprf iVCll Cetutr,J.tar r.J.11(7tcn r Dale
Lincoln By signing This farm. I hereby certify'thni dw ive lr-si wi s(were)abandoned in
County Paled ldewificilloa No.(PINT occurtlr;!lce with 15:1 1C 1C 02C.0100.ix 2C.0-100 I'Mel/Consinrction Efarlrkmis
rand Hrrf n cnpgnflhis rrturd lras beeir pmt iderllo l/re t+e11 orr�lcr.
5b,ll ltitudeand long-itude irr degrees:
(tr.ceu rvld,01w 4uiloll,k siltricicnl) 9.Site diagram or additional well details:
tiou tua�the the bacl:of this page to provide additional well site datails'or well
N W abaudoilmeru de(ails. You Inay also Mach additional pages if necessary_
(YDNSTRIit riox DETAILS OF WELL(S)BEING:ABANDONED SUBNtr rrAI,tNSTRU('TiONS
:!(Iudr treU wrvtrai•Iron rrcvrrllsl!J'uvrJilml�le. Fro trrahlplr iJ�ciiwr rlr rtirn•uxtlrr slrlry:fP -
nxll.,UNI.t'ntffi rim svmgroJrsrrvrrwJc Livahun:Je>ar.�a a mnsJrbmit cure) n 19a. For All Wdk- Subinh lbis rant within 30 days of completion of nrll
Ga.ideal[D#:
DMW-2 'abandonment to the folloi ing:
Division of Water Resonrcm,Information(ft.) Ptpcessing Unit,
Gb.To tat well depth:
65 1617 A.bil Sciniee Center,Ralci h,IYC 27699-1617
10b,y'or Tti Iecilon Wells: In addition to sending the.form to the address in l0a
Cie.Borehole dhRncter;2 (iu.) above.also submit owe copy of this foma within 30 days of completion of well
abaudounicnl to the.Collottirig:
Division of WalerRsourc s,Underground hipctlon Cottwol Ptngratu,
6d,Water lcvd below ground strrfacc; (ft.) 163E tilail Senicc Center,Italcigh,NC 27699-I636
Ga Outer casing Icn, h(if Imon n); (f1) tile.For W&I'L SunrC Si ay. .iuiean Il�c; In addition to senditig the form Io
the address(es) above. also submit one copy of this form within 30 dais of
completion of well abandonment to the c0imly licalth deparintein of[tie count{•
Gf.innereasin„ltnhing tcnith(if lmown): (ft.)
«•here abindomd,
G-',Screen leng(lt(if kumm); A)
Fonn GRr-30 Nonh Carotim Deµ umeni afEri0romnenl alb Natuml Resomces-Division of Ve'arcr Resoluces Revised August 2013

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WELL ABANDONMENT RECORD rot imeri,alUWONLY:
This form can be used for single or multiple,Ive11s
1..Well Contractor lgfor•tuation: WFLL ABANDONh1FNT DCTAir 4 ;
Brian Ewing 7.L Number of Bells being aliandaued: l
Wen colinclor Nmnle(or,rtill as 11ey P csanally:Jlv2nAmiln;,.ell On hiMier limpen)) For nndople- N ferticut or slryJph- welts ONLY weth ibe mime,
CWJ3fr,iCft[NJ+tl'`d1YliN177A�77f,IYJN Cia1P S7J1V71lf i}1�?fU1711.
4240-B
NC tYell CarttmctorCcdlt,ctliou NnnCJcr 7b.Apptvximate volume of water minaining in well(s):
SAEDACCO FOR 1VATE)R.SUPPLY WELL.5 ONI.V;
cxmpanyName %Tyyrc of disinfectant used:
2.Welt Construction Permit d:,
L&alf a7ppOeuble wellpuRrAw fi.e!Cw-ah-,Sme,Yorlmxe.br eaim7,,elvj tfkwwn 7d.e4r110Unt of disitlfectsutl USet1
S.Nell use(ehedcWell use):
NVater Supply Well: 7c Scaling materials used(chcck all that apply):
ElAgricultunl pMunicipalt ublic N Ncat Ccfuent Grout ❑Herdonitc Chips or Pellcts
0(kVilicirn:d(Hcatingto©lino Supply) ❑Residential Water Stippty(single) ❑Sand Cement Grout ❑Dry Clay
❑IndustriallCoun immial ❑Residetrtinl Watcr$apply(shared) ❑Concrete Grout. ❑Drill Cuttings
171rti ation ❑SpeLiahy Grout ❑Gravel
Ron-1Vater Supply Well; ❑Benlouite Slump ❑Other(exp lain.under 7g)
I9Mnriilorim! ❑Recovery
injection!Veil: X For each uuterial selected above,prvsido;tntotlot.of.m;itcrials used:
❑Aquifer Rcclmrge ❑Grounds aler Rcntedi nion Neat Cem.:941b ,Wtr•7gal. Sand Cem.•lb ,Wtr:gal.
❑Aquifer Storage atxl Recoven` OSalinity Barrier
❑Aiprifer Test ❑Slonrml8ter Drsiliage
❑E\perimetmal TLchtlotoL_v ❑Subsiderre Control 7p,Pr•ulvide a brief description of the abandonment pevoeidum:
❑Geothermal(Closed Loop) ❑Tracer
TREMI GROUT FROM THE BOTTOM TO THE SURFACE
OGeothermal(Heatinrt+Cootirig Return) ❑Other( lain under 7tt) I -
4.Date Wcu(s).abandoncd: 3-25-24 QPR 2
c t3
5a.Well location:
Warlick's Grocery .Ge`:��•:J•�v 1
racilitylthA•tvr Narnc ra:iliTv]Ds iiruppli able) 8.Cellitication:
2673 -Plateau-Rd. Vale, NC 28168 Bd Ewing-n 4/2/2024
Physical Address.City.mid Zip SFcarhltec,rt eittr>4•ri wen Contr=wr:,r,,.'al`(hvmr D:Ac
Lincoln By.sJ-sg7b{3 this form, 1 hereby certlf}'that flee ire11(sJ was(trere)abtuidoned in
Catmiy NVOCI ldcrglfi601L No.JPIN) accVnIancc With 15A A1CAC 02C,01,00,or 2CA200[Pell ec7JJ:sineclion Starukirfls
mid dim tr cgnJ*oftlris record]rtu beErr plrovidetl to dre hell otmer.
5b,i lthudeand longitudc in dcgrccslneinutestseconds ordccim;oi'dcgmcsi
(irwell raid,01be WA01ig 9.Site diagram or additional Nell details:
You mad-use the balls of d►is page to provide additional well site details or well
N W abaudoiurtem details. You nray also ul teh additional poges if rtecessan_
C'ONSTRUC- N nrxAFIS OF%VFLLN BFFING ABANDONED STTRNVFITAT.TNSTRTTt'TTONS_
:Iflnsir Jf[ll LY/!L5'lrmL'lliJfl mx1rd(5)11'a4Wal,1la. f,ar mulaplY i��ettiwt cu'rs�n-unttr'zypph'
wells ONLY mirfl tlAe can mrhnrt l wrehem. 10a.Far All WeIN: Subrah thk fomr vnithin 30 dabs of completion of n>11
Est.Well me MW-5 abandonment to the following;
Division of Water Resources,Infortuation Pracemin;t Unit,
6b,Total well depth: 35 A) 1617 NUB Scnice Center.;It rlei�ly NC 27659-1617
10b.For-Ttilcolon FVells: In addition to seeding the form to the address to 10a
fie.Borehole dianuter,2 (iu.} above.also subndl one copy of this form within 30 days of completion of well
abaolomrtcm to the tollawing.
fid,Water Ic�'c1.bc[On vend nrr6rcc (feJ Division ofWaler Resources,Underground Injection Contrial Program,
1636!!tail Service Center,Ralci;;h,NC 27699-1636
6c.Outer easing length(if known): (t't:} 10c.rnr•1grr..i iglu,.e Utiectian In addition to sending the form to
the"address(es) above. also submit one copy of this fomr within 30 days of
completion of vyell abandonment to the county health depanmetd of the county
vylJcro ahlndomd•
6f.Inner easin,Jtubinp length(if l;navvn): (ft.)
6g,Screm lettgth(if known): (ft.) i
Fornr GA'-10 North CarolLn Depaitincra of Pnvironmcnt soil N:uuml Resmares-Division of water ReSOIL t.l Revised Attpuss 2013
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AVELL ABANDON.NIENT RECORD rotlieem iu-cony:.
This feim can be used for-singie of mullipteiiells
1.Wctl Contractor Information: )YELL Ati 1NI10NNIFNT ni;TAtt_IS
Brian Ewing 7a NumUer of stills Uciny;a�anddncds i l
ny)
lVelfCotYrncloiA'ate(or�ticltownvYpcagsratlyatnant5n�igacll.ontiisflcrpro�e tea• rerrdrinle o"ectimi .or. axlmiwe'r ;supp), wells ONLY Willi elm. 'tw) .
' � earatfrrrch�w,'re6mhl�Noin�u,inn cior.suluiiJf'�YrejFtrtn,
4240—B
�NE1YdlCbntrhaarCbtlificaifopNiitilict 71).Appniximtitcsninrrseufsbatn-nefm:irn' iugiutrell(s)i •. (gal)
SAEDACCO FOR 3VATF.RSEUP.PLYIVNLIS ONLY: .
Corvpwl Name 7c.T3q)c'of disinfectant:used: f, '
2:}Vdl Coustruction Permit -
' '11s?tdlup;illiYrhleu�!lperraitr(i.tCumrtrp,Stcti,l'arimxr:L;rr7fnr;.rlc:lVfrGmwn _ 7d.alinonnCofdLilnfcct,iutUSed:• I -
3: Yell use(checicss ell uxe):
Water.Snpply Well: 7c.Seating mitcrials;tiseil(chcdt ali i6t apply):'.
I7rtgricuttiti ti bmuniciplVE'uhlio It N.Cat Ccnicut G"t ❑-ftntonitc Chips or Pellets.
l3 imth m at(Hcatin►g/coolirig Supply) Upesidernial Water Supply(single) • '❑Sand Cement Grout ❑Dry Clay
❑hdiistrial/Gommcicial ❑Residential%Voter Supply(sharxd) ❑Concre(e Grout ❑Drill Cullings
❑itti tiau-. ❑Speciaht Gtut ❑Gravel
lYcrn-Water 5upptr.-�Vcll;" 13:Hentonite Slurry !' ❑Other(explain under 7g)
A9Monitarir>g ❑Recovem
Injection Well: 7f,For'caeh tnarerial sclected'above,ptioside amount df.nuiterials dsed:
❑ uifer Rec �e E3Gr6uhdu:uer Remeduiiion
Neat Cem.:941b ,Wtr:7gal Sand Cem::lb ,Wtr:gal.
[]Aquifer Storage and Reco'ven, ❑Salinity,Darricr .
❑AiluifeiTest �Stontn�ater.Drihiugc ,
❑Experinterital Tcrinwtoev l]Strbsidcnec Cotxtol 7R Prtiside u brief dcsci iptian df the i I)audnnment pntct durc:
Mueothennal{Clo5cilLoop) OTtacer
TREMI.GROUT.FROM THE BOTTOM.TO THE SURFACE
®Gco(hemiat(I IcitinniCdolin Return). ❑Othert'nlain under 7 g)
I.Daiewelt(s).abandoncd: 3-25-24Aft zQ
i.
Sa Wellaucation: 274,
Warlick's.Grocery
8.CcnlRcatiait:
U
Txil raeiliq�lOrsttcrNwtoe itrlDa(i1°applicablc)
2673.Plateau. Rd..Vale, NG 28168 Brian n. 4/2/2024
Phtsical'Addres,Ciiy,'dndZip SigmhRCOrc0tifiodWeilCmruarclai<; ;11Ovt r .Daic
Lincoln {ly sigi ing tlds jorttr,l hemby certify,rlint rise trellis)irds(teen?)ahandoned inCautsiy Patr:t:llit:dlificaOii No.(PIN) r+CctttrlrritceiviUrlit.�C11C"t72C.01fA7.iir?C:OtO{1Tfc11:GwrislruclfarrStnnrkmis
and lfriit o crpyofrlris record has been pmvid dto Itre trell awner.
Sb.I ntitudcanil longitude in debmcesfminutoslsecuntis oedccimal°degreesc
(Ifti•e11 fold,Oise,U411g'is m0cicty) 9.Site di.�r m)or additonal st"cll details:
You riia}_use the bad:of Ulis.paga to')iro}ide,additiottaftsell site details'oYi4e)1
.abandotuuertirfCEML .Yeu stray also:utarU iidtiitiotml pages if tieeessary_
C&STR1iC1'ION DETAILS OF WELLS)BEING AB;6b6NED SURMriTAt.iNSTRCTCTi0NT5.
.4112th trill evaYhTC idU retwd;s)'if aiW141k. •Fur mulaple iAjec6eu'iir ron-miter supply
u,rils010IriUr can hrbmiicvrelunic. 10a:For eU1 3Ycllc: .Sirbrnit-Ibis fomr tithio 30 da�`s of completion of-tell
6a Weil IDS: Mw-6 ;tbaodonmcnt to the fallotsing
Dliisirin of Water Rtsonrcr�,Infutnwtion Proe�siog Unit;
Gb 35 1617 tllail Schice Ccatcr;Raleigh,NC.27699-1617
,Totatmell depth: (nl.)
10b.For-I'm Icetion Wells: In addition to sending the fume to the alduess in:10a
Ge.Borehole dialuctcr:2 (iu.} above,vise subudt one copy of this fomr NOlIku 3U days of comptetion of bell
ahbindoinntmd lrr the foflm iIig: IiI
Diviston of Witter Resources;Upder rpund injection.ControlFrrigralu.
64L Water lewcl.belosr_grotand surfacei (ft.) 1636 Mail Service Center;R rlcigii,NC 27699-1636
loc.ForWatgr So nh•7F infection WON to addition46 sending the fortis-to
6e.Outer casing length(if Imnsrn): (ft) the address(es)_aboie. also submit,one'copy of this form wilhiir 30 dajs of
comptctiou of well abandahmenr to the county fleapit depanmetu of(tic county
6C.1unrx easiniRubins;tenigh(if tmmm): (ft) where aExtndonctt,.
l
6g.Screen length(if known):
Farm M140. North Carolim lklnpnxtn of Entiromncat mid Nartrtal Rcsotuces_Division oC)Yatcr Reno ' Revised Allpsi 2013
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WELL ABANDONMENT RECORD . For tromml Usc ONLY:
This fotm can be used fir single'or mtdlipta)cells I ;
I.WcH Contracture infor'mntiom- ) rLL ARANDONNIENT DETAMN
j
Brian Ewing 7st,;!iwitber of ire lls uelny;Jilt tndon ld:'1
1YclfCanthartorNal>k.(orwLllmvr�petsflnallyatiam[onhigescll.unhisll�rpraperty) feu rHufrlph. t1Jec4tae or rrrJ-iitrrir supphv welds ONLY with the smle
- rnnsfnrca,Ne��6oiecinllNn�af,IY1N[WP 5711glne�lefbP!)I,
4240-B.
NC}Yd1 CktrilrldorC�ttiticatioii Nmrbci. - 71t.Apptn�7mxtc wtinine oftxrtt�rrmuining in il'ell(s}: (�aLl
SAEDACCO TOR WATER SUPPLY WEM ONLY:
Couvmn}'Name 7e.Type Uf disinfectgtit timed_: P `
2AVeti causttuction•Pertuit tl:.
Lf4all vpplh'aNeuQ1 parmi ts g.c Cuvn, S&:ta,'1'urJrure:lxjec Linn rlc}lffixuwn - 7d:elinOnn[of dlslttfcctsiut'uScd
3.Wet tis+e(ett0 ,Well nse)i I i
Water Suplity Weill 7c:Scaling matciiaJsuscd(chat;all that ajeply):
pitgritnitittat gMtinicipal/Pllbita CO Ncat Cement Grout I ❑Hcraonitc Chipc or Pcllct�
Mkothcrmll(Hcatin)Cooling Snpply) Qltcsidenti,d Water Supply(single) ❑Sorg Cement Grout ❑Dry Clay
QlndlisttiaVCvauncrcial ❑Rcsidcntinl Wntci•SoppW.(PDh3md) ❑Cordele Grout -b Drill Cnttint s "
❑Irri lion b s&dadty brunt d Gravel
WI-Water SUPPkv Nyvil.- 0 BontorulteSluny ! ` b'`Uiber(espiaitt under 7g).
(�hloidtorine_ 17Rccotety
Injection Wcltp X For eaeh ttiamrf:d selcmd'above,proridp amount of.tnateriats[teed:
13Aquif4Rcchmrgp, 13Grounduale'rRentedi:itinn. Neat Cwi-.:941b ,Wtr:7gal.. , Sand Cem.:lb ,Wtr:gal:
17AquiferSton1ge and..Recover• ❑Sa by Darricr
❑Aguilar Trsi QStonmctttcr.Drvitiugc
❑E.xperintental Techuoloey tiSttbsidetre Cotntul. ?g Prtnidea brief description of the ul►antlnutncnt pn!c(ylun:
17Geothenttat(Closed Loopy 13Tiacer .
TREMI GROUT FROM THE BOTTOM.TO THE SURFACE
®Geothetttmt(HeatinalCooiiti Remm) ®Other(explain under 7R) . . _
d.Date retl(s1abandoned:3-25-24 .
&L Well location:
Warlick s Grocery .
8.Ccrtitiistioir: L,tt a 'w�,
Facilitll0nncrNamc Fa:ilitrrIDp(iEappli.ablc) •
2673.Plateau Rd. Vale, NC 28168 B.rha h Ewin Lv, 4/2/2024
Physkal'tlddtc s.Gi 7;dmd Zip 5i Inrcrtf Ceitirrerl.{Nell Guui Kliit:;r r,',tl Chrrkr" Date
Lincoln 13y sigyzhW this fiarm4 7 heoy certify,dial the u•ell(.$)wax(were)ahavido»ed!or
Couuiy P�ncct Idcotific3llnuNo,(PINj 'ammianvu ivith I id VAC,021 ,D10a.ur 2C.0200 fFE1l Cmisthiction Strinckmis
acid d ri t a copy 6fdhis record has been p"nwided to the hell mcner.
Sb,I.ttitude'and longitude in grgivesdminiites/seconds or dccintal'itcgtresr
(INvell Prttd,01W L'llllungis matlrcktti) 9.Site diagram or additional well deta11s:
Too nut}'tueilk baclt"of this.page fW06ide,'addilioiml Wall site.&Wis or null
N' W .abandoim em details..You may also aiiach d.ffl ional pU s iftlecessaty_.
CONSTRIIC ON.DFTAIL.4 OF WELUS)DEINC AHAAbONi D StUBM17MAi,iNSTRIJI.CMNS
:tflrrtlr Nell cvrrs,rttrtirla triratxlfsl lj oiallri�ld. Feu'rrmltiple illrrrfan'iu'ffun•nwlir supj!!}' � '
ue(1.s.ONLYmJtlidresnm�rwrsncctemcdLmulwrr.Jcnif,i�uinusitLmliwralirnre,' 10a: For All Wells: Subrnit-lhi5 fami%tttWn 3U drjy5 of zompiction of titirll ,
6m Wcli IDils MW-1 aWbdoonrcnt to'thc following:
�.
110hion of Water Resources,lnformmtion Processing Unit,
6b.Total weft depth: 35 (fb 161711 O..Sciyice Centcr,Itoleiytfi,ltiC 27699-1617
tOb.For inikilon Wells: In addition to sending tLe forni to the address in l0a
Go.Borehole diatueter 2 (in,) above.tifso sU�tidt ouc ropy of this fo'rin Wroth[[30 dUys of completion of%[-ell
a b ndonnt.ent to the follmtt'itiy.
Mistgn of Wa'ter Resources;Underground iiiJection Contrvl-Mgram;
Gd•Water lovd.bchaw•grotind surfaced. (ft.) 1636,,loll Scnicc Cenfcr;ltalcigh;ItC 27699-1636
loc.Fnr•%Va jjr @11inly iniectfon W�11g: In additio0 to siatding the fomr to
6c,outcrca.(ing Imptb(if l�nRn): (ft') the addresses) abom also suOrnit,' copy of this.fomt tvitbity 30 days of
cvmpiction-of 1VA abandoiunent to theta ilnly health depmnntetd of the county
6C Inner wmin:�tubiug tenj,-th(if lmown): ( ) where atnndonccd..
j
6g.Scr•ecn long&(if known): (ft)
I
Form MI-30. Nonf Camtim Iklnrupem of Erivirooment void Nimumt Rcsommes-Plvislan of Water tt,CsaaIL1`.s I Revised Auguse 2013
i
j .