Lincoln_Well Abandonment_20240624

WELL ABANDONMENT RECORD Fat haaml Use ONLY: —
1.Well Contractor Iafarmatton: WELI.:s.RANDONR'dEN-17 DETAILS
( L')r4 ;c V-(%1l( , -� —---- 7a.For G-Probe/DPT or Closed-Loop Geotherwwl Wells having the same
WOBCoottarw (arwYawaarpois Nyaiaodot�gwellonhvharpnromy) well cauwuctiamldtgilt�lylGW-30i;ueeded IodtcateTOTALNUMBERu(
L�`�`� !) wells abandoned:
NC WA CIO�`� liatit 7h.Approilmate volume of crater remaining in well(s):�j _(PL)
--I�-Y ri� \ram t\c a� li. � FOR WATER SUPPLY WELLS ONLY
Cotap yfie.
r-- J 7c.Type of disinfectont used: J k1tt�Ftn
2.Well Construction P.10 t N: 1 -61-16`l
Lot a0 appliruh)e.ell owu4vkri .pwwira Cf.a UIC,Coanry.swe,i'ieiwme,04.1 t(kWun
7d.Anumat of disinfectant used:_ i Gtln.-)
3-Well nw f l."*we" --
Water Supply Welb 7e.Sealing materials aced(check all that_apply):
OAg iculttual QMunicipal/Public Q Neat Cement Grout , lemooite Chips or Pellets
❑Geothermal(Heating/Coohgg Supply) Residential Water Supply(single) Sand Cement Grout O Dry Clay
olndwuiaveommettial OR."uItntial Water Supply(shared) Y Concrete Grout Q Drill Cuttings
Qlrri ation ❑Specialty Grout Cl Gravel
Nos-Water Supply Well: O Beomnite Slurry 17 Odwr("plain undef 7e)
O)Ao ruto;ing nRNeve„
Well: X Fw anti ntauletiY selocled above,Provide&meant of materiels used:
QAqutfer Recharge ElGroundwater Remediation i 1
OAquifer Storage and Recovery QSalmity,Banner
QAquifer Test QStmmwoter Drawa&e ( tie 1'o..,.r't` �JY;_, _
❑Experimental Technology QSubsidence Control r�
7S PravYa a irinf description of the abaadawset procedure:
QGaothermal(Closed Loop) QTracer r..�.
00colherrml _eating ooF Return) QOt>set . lain under 7 ' -1 .:
C.Date wen(.)atmodognt 1,— ` ` i" Lh
1(
Sa.wen location:
FadkKlovorl ma Facility W4(ifawiaWa) L JUN r c: 2024
Me A&hw Cky,sect 8'a of Ct+tilkd g Cauaaetor a Waft pt.i'D ;s
L�-mac(,i,,-� t ti� ; ZtaDyz 2! 5 `�
� oe
. Rr.riprrinq Ibis fra.tn,/heeobr cerrrli char the sort/(s1 was(were)ohandnned to
County Parcel IdenhScatnn No.MN) accordance with I SA NCAC 62C.0/00 or 2C.0200 Wdl Consinichon Vcrudurdt
and that o copy of/his record has been provided to the xr7f onrner.
3b.Ludim a and bogNinle in degrees/mfumes/seconds or dedinal degrees:
c' 9.Site diagram or additional weil details:
AZ5 -� >-r~ iv . Q _T- You may use the back ul ilm pu>?c io provide additioual wefl site derails or cull
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DET It S OF WELL(S)BEING ABAKIDONED SUBMITTAL INSTRUCTIONS
:!uarh nrNmrtcrrrctra+r re:ard(�)ifarvilable.For.^r�nple ir�jFcrioe orroa-timer sapply:rrl)s
ONL y Hirt the.came eor»rrnertonleboadaamenr,lea eta+_mum it ems form.
r 10a.For All Wells: Submit ibis form withui 30 days of completion of well
6a.Well IDll: abandonment to the following:
�� r Division of Watcr Resources,taform.tion Processing Unit,
6d.Taal sell dentb-—L`— (!L) 1617 Mail Scrs ice Center.Raleigh.NO-27649-1617
1 t 10h.For Infection Wells: In addition to sending the form to the address in 10a
6e.Berme diameter. 7 �1 above,also submit one copy of this Ran within 30 days of completion of well
abandonment to die following:
6&water level betow grouna surlsee: �/ (R.) DhIslon of Water Resources,Underground Injection Control Program,
1636 Mail Service Comma,RnlcW NC 27699-1636
6t..Onter casing length(If hnnwny �d i 00 [ft.For Water Sw wtv&Inlection Wells: in addition to sending the form to the
Wcl. a-j al,ove,nL+v>U as stile-py of obis fir ru Wlifiiu 30 days of emnpleiiva
of well abandonment to the catty health department of the county where
6f Inner casing/tubing length Of known): N/09—0L) abandoned.
69.Screen ica&(if
Farm GW-3tt Now Carolinas Department of Environmental Quality-Division of Waer Resources Revised 2-72-N 16