Transylvania_Well Abandonment_20221028 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Edward Wyllys Taylor, Jr.
7a For Geoprobe/DPT or Closed-�oop Geothermal Wells Laving the same
Well OmmucmrName(or well owner personally abandoning well on his/her property) well cons[mction/depth,only 1 GW'30 is needed. Indicate TOTAL NUMBER of
NCWC 2440-A wells abandoned: i
76.Approximate volume of watcrlremainin m wells 0.63 sL NC Well Contractor Certification Number pP g (): (g )
Geonetics Corporation FOR WATER SUPPLY WELLSONLY:
Company Name i
7e.Type of disinfectant used: 1
7-Well Construction Permit At: NA
Lrat all appfkable well construction permits ite.VIC,County,Siafe,rariarue,eta)iorj u
7d.Amount of disinfectant used:
3.Well use(dreckwell use):
I
Water Supply Well: 7e.Sealing materials used(check all that apply):
DAgricultural OMunicipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
OGeothetmal(HeatingtCooling Supply) DResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
DlndustrialfCornmercial DResidential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
01crigation. ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bemmnite Slurry Cl Other(explain under 7g)
!!Monitoring ORecovery,
Injection Well: 7E For each material selected above,provide amomt of materials used:
DAquifer Recharge DCnomdwater Remediatioa Approx.0.29 cu.ft.bentonite chips
DAquifer Storage and Recovery ❑Salinity Barrier ,
OAquifer Test ❑Stormwater Drainage
DExperimental Technology DSubsidence Control
7g.Provide a brief description of the abandonment procedure:
DGembermal(Closed Loop) DTmcer Removed manhole cover aInI and well plug
OGeothermal(Heating/CoolingReturn) DOther(explain under 7g)
Measured total well depthland water level
4.Date well(s)abandoned: 10/11/22 Poured bentonite chips into pipe and manhole
5a.Well location: Hydrated bentonite chips hydrated and replaced manhole cover
Shamsuddin N.Gillani Property 00-35046
Facility/Ownerblama Facility M#(if applicable) S.Certification:
1591 Old Hendersonville Hwy, Pisgah Forest, NC Edwcw&W. Taylor,Jr 10/13/22
Physical Address,City,and Zip Signature of Certified Well Contractor ca Well Owner Dane
Transylvania 8596-57 4988-000 By signing this form. T hereby certify that the wells) was (were) abandoned in
County Pamei IdenfificationNo.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy ofthis record has been provided io the well owner.
Sit.Latitude and longitude in degrees/minutestseconds or decimal degrees:
(if well field,ova hit/long is sufficient) i
9.Site diagram or additional weli'details:
35.25430 N -82.70051 R 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 WELL(S)BEING ABANDONED
Attach welleonstrueaon mcord(s)rfawdlable.Formultiplehymfinormn.wmersnpplywells SUBMITTAL INSTRUCTIONS
ONLYwhh tins same constructionlabaulamnenr you con submit one force I
10a. For All Wells: Submit this farm within 30 days of completion of well
6a.Wen EN: MW X abandonment to the following: i
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 10.4 (ft.) 1617 AM Service Center,Raleigh,NC 27699-1617
lOh For Intention Wells: In addition to sending the form to the address in 10a
tic.Borehole diameter. unknown above,also submit one copy of i
m s form within 30 days of completion of well
CCGG abandonment to the following:
6d.Water level below grodsurface: 6.`�`� (fk) Division of Water Resources,Underground Injection Contra]Program,
1636 Mail Service Center,Raleigh,NC 276994636
6e.Outer casing length(if known): NA (fi,) M For Water Sunaly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this fora within 30 days of completion
NA of well abandonment to the ce mty health deparhaenl of the county where
6E Firmerwing/tubing length(if known): (ft.) abandon'
6g.Scrmr length(if known): NA 00
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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