Lincoln_Well Abandonment_20240617

WELL A13ANllUNMI N'1' RECORD '
For Internal Use ONLY:
1.Well Contractor Information: WELL,ABANDONMENT DETAILS
' 't` � �ir7.l t�Gt S 7a.For GeoprobecDPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abeadoniag well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2L 113--A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1
J `
>L t^U^ ci S. r I et- I l)rY\ (gal.;
t� �� FOR WATER SUPPLY WiELIS ONLY:
Company Name r
7c.Type of disinfectant used: If T f+
2.Well Construction Permit#: LL H. IA/2 "0 1.7.7L(
List all applicable well construction permits(i.e.INC County,Stale,Variance,etc)((known
7d.Amount of disinfectant used: C (/f
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that a !°Agricultural DMunicipat/PublicpP y)
0 Neat Cement Grout �I3attottite Chips or Pellets
°Geothermal(Heating/Cooling Supply) tiesidential Water Supply(single) 0 Sand Cement Grout
t7lndustrial/Comrncrcial 0 Dry Clay
L7Residcntial Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
°Irrigation
Non-Water Supply Well: °Specialty Grout 0 Gravel
°Monitoring °Recovery ElBttNonite Slurry °Other(explain under 7g)
Injection Well:
7E For each material selected above,provide amount of materials used:
°Aquifer Recharge °Groundwater Remediation
°Aquifer Storage and Recovery °Salinity Barrier S
°Aquifer Test ❑Stortnwater Drainage
°Experimental Technology °Subsidence Control
OGeotherrttsd(Closed Loop) °Trnccr 7g.Provide a brief description of the a odonment procedure:
°Geothermal(Ileating/Cooling Return) °Other(explain under 7g) S 1 r ) (j 61
4.Date well(s)abandoned: 7-
Zu -- •W ` `•" ,/
Sa.Well location: JUN 17 ZfZ
r >04 &x&f-f S+ j r
t'
Facility/Owner Namo FacilityIDR(if applicable) 8.Certiliclon: Uyl.i..,1t yo
4041 jc,2'7 i-twl -i-r-or.A--zt..TGvvkiGr 200go i//
Physical Address,City.and Zip 1!� ,� 7 Z
Signature of Certified Well Contractor or Well Owner Date
I_ t4\ t`oly\ 07-0L(O
County By signing this form, I hereby certifr that the well(s) was(were)abandoned in
Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Constnlction Standards
5b,Latitude and longitude In degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(dwell field,one lat/long is sufficient)
9.Site diagram or additional!*ell details:
N W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELUSI BEING ABANDONED
Attach well construction record(s)ifavallable. For multiple injection ornon-water supply wells SUB1bQ1TAL 1NSTRUCTIQNS
ONLY with the same construction/abandonment,you can submit ane form.
,t r /A/L 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: /i. / abandonment to the following.
5 V Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) 1617 Man Service Center,Raleigh,NC 27699-1617
fir.Borehole diameter:
IOb.For Iniection Wells: In addition to sending the form to the address in 10a
(In.) above,also submit one copyof this foam within 30 daysof completion of well
abandonment to the following:
64I.Water level below ground surface: -3 (g,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Av /A (ft.) 10c.For Water Sunnly&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
r !/ of well abandonment to the county health department of the county where
6L inner casing/tubing length(if known): Ali A (R,) abandoned.
6g.Screen length(if known): /ti /A 0.0