Buncombe_Well Abandonment_20221122

WELL ABANDONMWM RECORD For labre l Um ONLY-
i.wen r tutu DETAUS
' � 7i.For GeopcoWD"or Cboeed-Loop.Geo�Wdkbav'mgft same
Won commerce Name(or wen owmrpsem.uy rbmdanh*well oa hielhetprcpmey) wen eeeatt wdan/dapW,anly 1 GW;30 is needed. Indicate TMALNUMBFR of
wdls abandoned!
6 a -A 7L Approadmsts vole of-aft to wen(a):
Nc wen coanaaer Ceedna.dan Nam r
FOR WA=SUMY WELLS ONLY:�T
e 7a Type of d1dofachat nod:
2.W�Comdevatlaa?ardt iti
lief aDappliae6k wellar osecpaartb R6 UIG Cawpb Pm(mrar;alc,!d 7d.Amount edecbant used: ' D
3.Well on(cheek well laser
Waller Supply Welt: 7e, naftrtala aced(theek en that appl9):
OAgricuffioal ❑Muniaipel(Pubho oNeatCement M (" �P ChipsarPeDets
C Oe &wmal ) cam ida�al Water Sappty(�) t s�C®coot t�+ a
mdustriaificousamw
oRe�eideatial water suppiy(abaed) �c OF0 N O V 2 2 2022 °DO cuww
ohdation o specialty(pout o(travel
Nee-water St p*WOM Cl Boutonite Shf►3t `-n, fir•^ kl tamer(eVWn:rider 710
DMortftft CRecoveay �*met(.
Welk 7L For each materW edeebed above provide emosM of mnft&ls and,
pAquifergecharp oarocrulwabw Raw diction Z G- (,�LA
OAgwfw St=V and Recovery oSslimty Bavier
Tent oSmrmaatrrDtninage
p Technology o3ubaidmce Control 7g. a bate[ of the PrOcedum
oGwd e W(Closed 'Loop) Eyrru r
oceothetmd. Keaton O tber under?
aa. as
4.Dote wdle.)almndoaed: ✓' 1,. `, a- Cz ✓\---------------------
C
51.well beadoas
Fan7Ity/OwoerNme FacIIityIDA(ifapPtioable) a'
Addmo.Ci%-dZip (� lWs can tawenowmr .
By s*rtirg side Jor^I hff*av*tlmt Av"Ws)mw(w m)abandoned In
County parcel MeadBadeeNo.MQ aceardisow wldl ISd NCdC 02C.0I00 or 2C.0200 Well Conwvedon SMndw*
and dint o copy cf dd&,ww has bees provided to the well owsW.
Sb.lAdh de and longoads is denretn/adaabee/seaonds ar daeiod depvw:
(ifwen field.cos Uft"is So" 9.ate disipm or addiMonal well datans:
I // o I //: you may use dw back of We psSo to provide ad or additional va site deWh well
3 5 3- N R a 4 4� W sh mdonend detat7e. you may also s#wIL additional pages if necessery.
�ttsschxYflea�.��rerlairraond(a1� PoraatrNp1t61N�oraoaawMs+gpiptad4
ONLYwdwsave 18s.For All waHr: submit this fan within 30 days of completion of wen
sbamldonmaeat to to following
62.wen IDA:
DlvWoe of Water,Rewvoea,Iafwmatioa Paooeuft U1114
6b.Total we9 depth: (R) "`A�Ll 1617 Mail swvke Caster,RmWg%NC 27MM617
10k For hatedfan WeW: In addition to sending the form to the address in Ift
6e.Bore3ceie disseeter: (le.) above,also submit one copy of this frxm within 30 days of completion of well
abandooaneut bo lee following.
6d.water kvd below grwud surface: (R) MvWao of water RMUreee Underpoand IRJs dioa Control Program,
1636 Man Serdee Center,RaWgh,NC 27699-169
6e.outer easlag (it down): (R) 1tk.Fe*water b2&&hd*e os�Wells: in addition to sending the fan to the
sddteta(ee)above,siw submit one eopynf this fora within 30 days of completion
of well Abandonment to the comity heal8c department of the county where
fL Inns adng/tabiog hmglh(it dawn): (R)
6&Same kn&4f down): tR)
Form OW 30 Nm&CmW=Depntmmt of&*ommnW Qadity-Divbion of WdwRmotm= Revised 2 22-2016

WELL ABANDONMENT RECORD For lmarmdUseONLY:
Well ndor Info a: wleia.ABANDONM OM DETAM
1.
�l rI r r 11� �^. 72.For G�eoprobe/DPT or Ctosed-Loop Geothermal Wella having the same
well construction/depth,only 1 GW,30 is needed
won couawwr Name(or wen ownerpeasemdly abandomns wen on in&rpmparty) fitdicmte TOTALNUA2BER of
wells abandoned:
a a — 7b.Approxiou"volume of water,remaining in well(s): (Bata
NC well contmaor certification Number
FOR WATER SUPPLYWELLSIONLY:
Company Nam c/' 7c.Type of didafeebnt used:
2.Well Cow*udfon Permit 1k
list all applicable mH ww&wdon permits(Le.MC,C-0%SMA,Vwftm din)rb— X Amount of disinfectant seed.
3.well use(cheetwen see):
Water supply well: 7e.Searing materials need('herb all that apply):
❑Agricultural ❑M ❑Not Cement(rout ❑.Heatomte Chips or Pellets
❑Goolfierrod(Heatmwcoolmg Supply) Water Supply(single) ❑sand Cement " a x , , Y
❑lndustciel/Commerciel ❑Rmideatial water Supply(shared) 0 Concrete� �"� `
❑firi ion °Speeia>:Ye>rawrt NOV 2,2 20n'him,
Non-Water Supply well: []Bmtonite slurry
❑other(captain under 7gJ
❑Monitoring ❑Recovery ''�yy i3Yn'rkq�?^ Ertel
Injection well: 7L For each mat+etli7"aelate�� O"e amount of materials now:
❑Aquife Recharp ❑(runadwater Remmdiation
QAqwfier Storage and Recovery ❑s dingy Bar:iec
pE��Test ❑StomrwatwDtainage
Txfinology OSubsidence Control 7g.Provide a brief dearriptlon of the abandonment proced v
❑Geotireanal(Qowd Loop) ❑Tracer 4) —,q
❑creothe®al ' Rdmn ❑other lain undo 7
4.Date well(s)abandoned: q a a
Sa.well location:
Fec�MWMw=Nuw \ _ (� (� Fa ft33 tM(ifeppBeable)
\ & don:
0.
---A N (�,,- , C,
Apical Address,may,and Zip C/�j"I 3iyde of c tlad W Qnhactor or well owner Dam
.A h CO ram.b`r 0156
a o(DO CD BY B this firm IlranbY aat{fY that dw well()wac(were)abaradoned'in
countyT— Parcel ideatificatIon No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Com tre don Swndmds
and that a copy of this rowrd has been provided to the well owner.
5b.Latitude and longitude In degreesholnutea/eeeonda or dexinnl dep m:
(ifwan field,ooeholm is sufficient) l �� 9.Site diagram or additional well details:
r E C Q You th
e m lade of this page to provide additional well site details or well N g a C o w abendoomout dalails. You may also attach additional pages if necessary.
COMSTRIIC't'IORDFTAM OF WE i.(S)BEING iB ANDONSD
AraAweilooasftvdmmw d(sl fowllabls.F-muf ple6tletd-ornor-waraupplywab
OALYWA dw sense oam&wdo A=domx-4 You amr enbedt e°n<Jaw — -
10a.For All wd4: Submit this form within 30 days-of completion of well
abandonment to the fonewing
6a.Well IDII:
c,.� Division of Water Resource,Inforuatlon Processing Unit,
9\,.p D l l�`� w 1617 Mall service Center,RaWgb,NC 276994617
�.Total well d ( )
lob.For Iniwti n Wells: In addition to sending the form to the address iA 10a
Borehole diasezter: (Q �) above,also submit one copy of Ibis form within 30 days of completion of well
abandcnmart to the fonowing: I
6d.water h:vd below ground eur[ue: V ($,) Division of water Resources,'Underground Injection Control Program,
1636 Mail 3ervlee Ceder,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (R) 10c.For Water SaMIT A Iniextion We& In addition to sending the form to the
addreages)above,also submit one copy of this foam within 30 days of completion
of well abandonment to the 'minty health department of the county where
6E Inns cadngitob(ng length(ff Inewn): (Da abed
69.screen leng1k(ff known). (its
Form GW-30 North Carolina Depadment of finvironmmtal Quality-Division of Wdw Ro an= Revised 2 22-2016

WELL ABANDON EM RECORD For hbomd Use ONLY:
L Well Coabnlar Iatsrtaatlaue
►^S 7i For [e-mail] mldWdshamg*oum
wen Ceobwmr Name(or wen owmrpa andly sbmdomeg wen an hidharpeepaey) wall eons rwdor/dapth,only 1 GW 30 is needed.Indicatie TOTALNUMBPR of
// Wdb abandoned-IA
-
oZ 7b.Approdmate vehmm of water remdraing in wdl(s):
NC wen camumdur Cat6adm Number
FOR WATJCR SUPPLY R►ELLS!ONL
Cmp"Nme 7a Type of
L wen conskadien PW=k
rtrr aII appHaobh wsD ao ato+:pw.dar(te wG Cowry srtre Pam ae1{fb w 7d.Amomt of disinfeclant cad:-- L a
3.well use(chectwen lsar
Water supply Well: 7e.sealing materials used(check an tbat applO
Mgr e� el/public Q Neat Carried(3rn y a"�C iB;�mte tamps or Pellets
❑Geothermal(Haling Cooling 3apPIY) ��es donna VYdw SIWIY(single) Q a® �Y
orn�iavca�l , MU&ImW water SWly(st Or N 0 V 2 2 2 02 C�
Ilm 'on Q speadshy(hunt
Non-water Stapp[,Wan: C Ba*c&o sling`pco►,W'a---) (wwWn under 7s)
❑Monitoring Qgecovaty DvfQisoG
bdecdomwen: 7L For each materW seleeted above,provide amount of materials coed:
� pypquffwp,ablum per, 130ramdaatwitemedistion
Banim °
Tat. OStarmaata Drainage
Techaobgy OSubsidence Coutrol 7F OGw&ema (Closed 4) 0aer
G( Othe®ai uder 7 p+tir �o r� exnJ►��Q�h /t tyu
6 a
4,Date wan($)abandoned:
SL Wen location:
Fw�MWOw—None FacltltyIDfGfspFH�ls) & ._
Adh....Cil%Td tip ) of 0 e count as Well Oarasr
Q 6 0-156 i6l o o a o By m4pft dds f0m l hw*coo that Ae w eWs)was(aerie)abandoned in
C-Bly punts]ldmdSadmNo."O aaaadamm with ISA NOW 02C.0100 or 2C.0200 Wep Cawarrtrdlon Aaedards
and dent a capytf�Fta mcord has 6omr provlded to the wen owxw.
Sb.Latlfade and k%ftde IN flog roedmtaata✓aaeeonds or dech ul degrvas:
(;twee fiCK am la IMS ig waffm all 1 9.site diagram or additlomO well deta&:
j I d C O L You m y use�e bwk of this page to provide a iMat el wa tits debark or weII
N C1 o W dmdmmeatt detaus. You may also attach additional pages ifnaxamry.
Amu*wdloaetbuadmreoor"tj a ForearENpt.6ylaegae�o.aa waft ypp�Ytnd1+
O11CLYwttJtthsamaw yn"eaurilliditaluwsn. 10s.For All wear Submit this fiotm wifbin 30 days-0f compldim of well
abaodonmout to the folbwing:
6&won IIW.
DlvYloa of watt Bmwcm,imerma Lion Procm ft unit,
6b.Totsi web drp&: 1617 Ma service center,ftWg ,NC 27694-1417
V IW For Iatecdm Welts: In additm to sen& the fotm to the addtom itr l0a
fe.IBore>tate ai.atett: (ia.) abo%also wbmh me copy of*0 form wi�in 30 days of completion of won
abmdmment to the&nowi W.
Division dwater Rmoaras,Underground Ddectim Cobol Program,
G&water level bdow grvmd smtsm 1636 Man service Cantu,Raleigh,NC 2709-16%
fe.onto eaadas bm<&(if mown): For weber Smolt'&IalKdim Wens: In addition to sendmg ore ftm to the
adihms(es)above„also submit one'C •of this farm within 30 days of completion
of well abmdomnmt to the coutity babb deputmeoR of the county where
6E Inner embeds dog lent&(if mown): tom) a el
69.Screen leas&Of low=): iD')
Farm GW-30 Nodh Cool=DWobu t of&avhoam nW Q=W.Dhn ion of Wdw Rmwm Rovieod 2 T2-2016