Buncombe_Well Abandonment_20221222

WELL ABANDONMENT RECORD For Internal Use ONLY: I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
:.'�Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW 30 lis needed. Indicate TOTAL NUMBER of
wells abandoned:
A
NC Well Contractor Certification Number 7b.Approximate volume of water I e inin�a in well(s): r7 (gal)
l
FOR WATER SUPPLY WELLS ONLY:
Company Name �-\ Pkr.J
7c.Type of disinfectant used: W � — ��or .
2.Well Construction Permit#: AD IL 1 O,Ss
List all applicable well construction permits(e.UIC,County;State,Variance,eta)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
.Wndustrial/Commercial ❑Residential Water Supply(shared) VConcrete Grout ❑Drill Cuttings
ElItTip,ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑Stomrwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracer
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) + A �_D V r
4.Date well(s)abandoned: `�� °��, N L_ ~'r s" '
5a.Well location- _ -_ n-f 2 L/ wner Name Facility 1Dli if applicable) IR+O+'f+cw3 1 f: . .5 .w 1
Facili
ty ty C PP ) 8.Certification:
121 1422,
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
BVLr1%'-oo'6. ��35`��`���� OL'COBy signing this form,I hereby certify that the wells)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with ISANCAC 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: (,
(rfwell field,one lat/long is sufficient) 9.Site diagram or additional Well 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable Formultiple uVection or non-water supply wells
ONLY with the same construction/abandonmen4 you can submit one form
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
1 Division of Water Resources,Information Processing Unit,
6b.Total well depth: L4 WS VL) 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (hL) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
t Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: A)
1636 Mail Service tenter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Q 5 (R) 10c.For Water Supply&Injection Wells: hi addition to sending the form to 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
6C Inner casing/tubing length(jf known): (ft.) abandoned. !hh
I �
6g,Screen length(if known): 00
Form GW-30 North Carolina Department of Environmental Quality-Division of WaterResources� Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
1 rcw,S Vr'-' V' 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW 30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
3255-A
NC Well Contractor Certification Number 7b.Approximate volume of water r e I'rung in well(s): d (gal.)
FOR WATER SUPPLY WELLS ONLY:Company Name �1 7c.Type of disinfectant used: W e11 —Ckko e- c��t1S
2.Well Construction Permit#: oc!���^ f7`3 3"I Lgj oal
List all applicable well construction permits(Le.UIC,County,Stat4 Variance,eta)ifknown 1'
7d.Amount of disinfectant used: ; �S ©•2
3.Well use(checkwell use):
Water Supply Well: 7e.Sealing materials used(check:i 1 that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
[I Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑r Sand Cement Grout El Dry Clay
*dustrial/Commercial ❑Residential Water Supply(shared) ys Concrete Grout ❑Drill Cuttings
111ni ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slur
ry � ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
[]Aquifer Recharge O Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology El Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothemtal(Heating/Cooling Return) ❑Other(explain under 7g) eov r
i' ., o - •+
4.Date well(s)abandoned:
5a.Well location: in1-0r 53VDn PrccwzLyg Urea
Q(� c q:-
17i 1�t*�oc�t- rnx+5 LLt;
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
T30 Pca�� 1�)k-t "Vwl aia'A'
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
&3539'4(-24 B signing this form,I here cerh that the wells was were abandoned in
y g g f by . ,;� () (were)
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.'0100 or 2C.0200 Well Construction 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.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailabla For multiple ilectionornon-watersupptywells ;;
ONLY with the same constructionlabandonmenx you can submit one form
10a. For All Wells: Submit this form within'30 days of completion of well
fin Well ID# abandonment to the following:
�I_ t Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: �+o c�. (n,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: , , (ft.) Division of Water Resources;Underground Injection Control Program,
n 1636 Mail Service'Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): ZS�I (B,) 10c.For Water Supply&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
of well abandonment to the county health department of the county where
6E Inner casing(tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): L— (ft:)
� I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016