Buncombe_Well Abandonment_20220531

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WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CARL CARPENTER 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple it jection or non-water supply wells ONLY with the same
construction/abandonment,you can submit one form.
A -4475
NC Well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): (gal.)
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLYWELLSONLY: ,; .
u�
Company Name 7c.Type of disinfectant used: MAY
A '
2.Well Construction Permit#: MA I 3 12022
List all applicable well construction pennits(i.e.County,State,Variance,etc.)iflcnou'tt 7d.Amount of disinfectant used:
3.Well use(check well use): rvy.�ta; Bd
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public El Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 1.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage -
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED IN PLACE
❑Geothermal(Heating/Cooling Return) MOther(explain under 7g)
4.Date well(s)abandoned: 03/03/22
5a.Well location:
CLOSED BUNCOMBE COUNTY LANDFILL 1101-MSWLF-1979
Certification:
Facility/Owner Name Facility lD#(ifapplicable) 8. �
2726 RIVERSIDE DRIVE WOODFIN 28804
�---�-�'�:� 03/31/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
BUNCOMBE By signing this form, 1 hereby certify that the ivell(s)ivas (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hat/long is sufficient) 9.Site diagram or additional well details:
350 39' 34.71" 820 35' 53.11" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple it jection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
LFG M W-6 abandonment to the following:
Division of Water Quality,Information Processing Unit,
Gb.Total well depth:
9.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): 6.0 (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013