Henderson_Well Abandonment_20230526

WELL ABANDONMENT RECORD For Internal Use ONLY: i
1.Well Coptractor Information: WELL ABANDONMENT DETAILS
�• �' ) 'Pw 14 PAooPk 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name 4r well owner personally abandoning well on his/her property) well construction/depth,only I GW 30 is needed. Indicate TOTAL NUMBER of
wells abandoned E
NC WellContractor can station Number 7b.Approximate volume of water rem i g in well(s):T•—(gal.)
t FOR WATER SUPPLY WELLS.ONLY:
Company Name lc.Type of disinfectant used: -—_9
2.Well Construction Permit#: �fi l S k
List all applicable well construction permits(r.e.WC.County,SYat�Varimree,etc)ifhrmvn 7d.Amount of disinfectant used: /:U a � 6 �()
3.Well use(checkwell use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Munici al/Public ❑Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ldential Water Supply(single) ❑Sand Cement Grotut. ,� ❑Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ncrete Grout 1 '��. {.r"�� ~nri#1 Cuttings
k tin Vi
❑ ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry MAY 2 2023I Other(explain under 7g)
❑Monitoring ❑Recovery nk rlr: air..
Injection Well: 7L For each mat�erlal seCe�.t��14vroyjde'nDirount of materials used:
❑AquiferRecharge ❑GroumdwaterRemediation
❑Aquifer Storage and Recovery ❑Salinity Barrier J
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under 7g)
A.Date well(s)abandoned:
5a.Well location:
utility/Owner lqame Facility IIJ#(ifapplicable) S.Ce li -
Physical Ad .Cip�, d Zip sigq6ToTC5er&WWe11 Contractor.or Well Owner Date
�iWJOV �`ML t f PS By signing this form,I hereby certify that I the well(s) was(were)abandoned in
Parcel Identification No.(PW 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:
(tfwell field,one lat/long is sufficient) i 9.Site diagram or additional well detaits:1
Q
`� You may use the back of this page to provide additional well site details or well
Cat (�V N ' R' abandonment details. You may also attach additional rages if necessary.
i
CONSTRUCTION DETAHS OF WELL ISI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavadable.Formultrple injection ornon-watersupplywells
OATLY with the same'construction/aba
ndo
nment,You can submit one form. 10a.For All Wells- Submit this form within 30 days of completion of well
6a.Well ID#: -At abandonment to the following:
�.( Division of Water Resources,Information Processing Unit,
6b.Total well depth: S (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to i ending the form to the address in 10a
above,also submit one copy of this form`within 30 days of completion of well
6c.Borehole diameter: (in•) abandomment to the following: ;
Gd Water level below ground surface: 401 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
t
lOc.For Water Supply&Iniection Weller In'addition to sending the form to the
6e.outer casing length(if known): IN address(es)above,also submit one copy ofthis form within 30 days of completion
of well abandonment to the'county hcalth department of the county where
6f.Inner casing/tubing length(If known): (ft-) abandoned
i
6g.Screen length(if known): ( )
Font GW-30 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016

Henderson County Department of Public Health
1200 Spartanburg Highway,Suite 100 i
Hendersonville, NC 28792
Telephone[phone]
WELL INSTALLATION OR REPAIR PERMIT
TO BE FILLED IN BY APPLICANT PERMITWi �ri5- tz�a�g�
Associated Permits (,n--le-r
Owner_/1tir: Iyin4 Ce.t,o 3 Sams WCO 'i r,►*s}re S Date %1/3/I-C-
Property Address 73 6re,, ro r4 -Phon 17 e6IST
Lot Size ,"1 AL- Subdivist
Lut-# 1
Pin# Oil Tank On Property? Yes �V No
Well will be used to serve what type of facility?
Individual(well serving one home) ✓�Yes No
Shared (well serving more than one home) How many?
Commercial(type of business)? Irrigati,n?
Directions to Property ZS Al 4n R Brno k5.I� r',�,.�, �, -1 a R N ,�;� Gr.o fta -tv
R Grti-� L+ur Fo {&t ,4 o-.4
DO NOT WRITE BELOW THIS LINE
STATE VARIANCE REQUIRED YES_ENO
WELL ABANDONMENT PERMIT
ALL WORK SHALL BE DONE BY A LICENSED WELL-DRILLER/WELL CONTRACTOR
THIS IS A DRILLED WELL
1- CALL 684-6060 7-8:30AM TO SCHEDULE
2- All work shall be done In accordance with 15a NCAC 02C.0113
3- REMOVE ALL PIPES,PUMPS,WIRES ETC. FROM CASING.
4- DETERMINE THE STATIC LEVEL OF WATER IN WELL.
5- SANITIZE WELL WITH APPROPRIATE CHEMICAL AT THE CORRECT STRENGTH FOR THE QUANTITY OF
WATER.(USE TABLE BELOW TO DETERMINE QUANTITY OF SANITIZER)
6- PROVIDE ENOUGH CONCRETE*OR BENTONITE TO ENTIRELY FILL WELL TO GROUND SUf�FACE.
(CALCULATE CUBIC YARDS/FEET FROM KNOWN DEPTH OF WELL).
7- HCDPH REPRESENTATIVE MUST BE PRESENT FOR ALL PORTIONS OF WORK(EXCEPT REMOVAL OF
PIPE/PUMP/WIRES.) I
QUESTIONS?CALL HCDPH
*CONCRETE FROM CONCRETE-MIXER SHALL HAVE NO FLY-ASH AS PART OF AGGREGATE
Permit valid for 5 years provided site conditions do not change.
Well location,installation and protection must meet state and local regulations,and must be inspected and approved by a representative of
the Henderson County Department of Public Health before any portion of the installation is put into use. Thelsiting of the well by the Health
Department staff is to provide protection from known possible sources of contamination. No volume of water is guaranteed at any site by
the Health Department.
3MIRLL CANNQJ B.LOCATED IN A RIGHT.-OF-WAY.
Date Issued 11 tilzL Environmental Health Specialist
Permit Received By ��„ 6,.-.,le Z

i
NVELL ABANDONMENT RECORD FaildcmdUsdONLY:
,. Ttua fotnl eati be used for sift..tar multiple tisells �� � •
I.We€1 contraimr inforniation: WELL ABANUOINMENT DEIA 4
Stefan Smith 3:t.1TumUerof%vOlsbcin{;nbandunedt.l
wt11&LraCiorhranie(4rsveIto1vIwi c ilatly, u,:ll.ailliisiltrr'tifbppty) A& rrtrrJnple &!fOEtar a VOM'=riafrr sgtJ%, w4olls ONLY wtlh tle, .svoie
r'!1{ fflfCf7iMJdl[+[)lii�alt1ht71f,iviN all?s7Jrs�J10'r rxiajFJN)L - -
3576A
A16'�Vcl!"GanlragorCcgiftcidieirNnni+er 76.Apprnicimate v{,tome of vvJltu•rentaininA in vi•rII(aj?1 ( al.)
SAEDACCO Inc FOR WATER.SUPPLY WELLS ONLY.
CoJnpam NSlttc: 7c.Tehe of disinfe tant used.N/A.
2.Well"Consttttction Permit tin:, -- -
L7�J teli;71},ali41761e wil per,rrir fl.4l LV7Jf7lJ,State.Y'arjbwe•.At(ecff(jJ7.,d1L J f teRJ15r7 ^Jd .1tt14ltI1t.Of.dlSitlfCCt:tltt used.
"
3.{Nell use(Ole&1rcll use):
Water Supply Well: 7c.Scaling matciirils used(cll�cl;all that apply);
p grictilftlta€ pl4ittpicip llft'ttRilic, 5d,Neat Ccoico,Gtoitt Gi g6itgii.JW Chips or Pellets
plac+tthcrlta cl(E3caRn>,_rVCoolitta:Snpply) ORcsidentinl 1V:•gter$5ippt}'f.lirigle) n"5and Ceittcnl d;mut D"Illy Clat
ohidustrialt't onmtcmial ElRmidentW W'atcr SoPP4.(sliamd) E :Conctete Grout El &rill C,doting
❑irri� fiou O speciultyGttttil [7 Gray+el
Roa\Vatcr.fiuppl}�Vctl; - CI Bentonite him, Cl Cther(ealtlairtuader 7g)
®141aititorine. OReioten
Injcetian`Yell•. if For each material selected above,provide atnountof materials used:
17Ailnifer ItccGalrge �Grtiuiid,i tier Rentedi uion Neat Cem.•471b, ,Wtr 3ga"l., Sand"Cem. lb ,Wtr gal.
I7Agnifer Stonlge tttxl RetgS'erY OS:diuily Ramer
oAtIllwrTest UStOtMwaterDrallog-
pExpeiiliten(nl Txllntrlogv p$ubsidct>ry Coistuil 7g;Prov€de a brief d6criptiuri of the ab:lildanmcat pi-#=hire,
t"JGeotlternnl(CrbsedLoop) IJTracer
®Gcotheairattliicatinttl'Coo6gReturn) EJ01kr(c-x laiftunder7;;) tremie_ grouted.
4.Datc well(s).abaodoncd: 5/1/2023 IAnV Ca fi 7��
Sa.Well location:
Lassonde Pappas Company }tf Gaie` 1 �
Faoilih�C7tvtrcr Nainv R-00v Min(ifapplknbte) R.CcrtilicstloitI::
985 Brookside Camp Rd. Hendersonville, NC 28792 �- l+ i• 5/9/2023
Physical 4ddn 9;City,eild Zip S iln>jjtL��.ff�/JJC�roiled%Velt 6merrvw pr 1V471(wtur Dine
Henderson !iu,sJsgJlr>t ths�lirJn,.!lie7tbk eerfrfy•dhrrt lJae well{sJ tr'(r•F(irere)rehnnduned in
Cdewtj I'areclldzi lrkditloicNo-(PIM) ctvl(Iffltie IMIP f U 'C-IC"d1 C,0100.oraC.0200 Troll Cojisfivdiu.ri 57 4(hirds
rJntJ fJrnf a capa,oJ'fliis rerurcl Jra3'hee7e pru�ideel:to fJre.ti el f nrr)ier."
Sb::Iattitodeand loa&r.lkin degmcslminutcslsccondsordixihii-J-dc ms:
(fr*C11 f-wW,o,a WA=g:(S a4ft=5.co) 9.Site diagram or additional well details•
35.378088" 82.489455 )(Ou ttm}'.use gibe back of this p0��e to pra}•ide additionat well.site,details:oe well
`V Aiandoulueiu details You tarry also ttttacli:i"tional pages if tiectssalnl.
CONSTRI7-MOLYDI:TAILS(IN W! LLf51 BEING ABANDONkD SUBNiiTTAT.TNSTRUCTiONI5
Alkidt nrl)cwr}•h=fidr1 rmird(2q if Ut•wUlk. 1 lir withiple hVei ,irr ;rdfl-wa74r-PA,
welts 01AY.ultfr Ike Yew 4112 4dijnil arr wrrr Mai Fai All Wells: S,ttittnil thi.5 fonts tiithin 30 ilay.j of eotupletian oC Well
6a.`Veil ID#...W-7R1 atiandanment to thc'following:
Divisian of Water,Rpsourecs,Inforwattim Prucesriny,Utiit;
6b.Total ivell depth: 15 (iL)" 161711 ail scnicc Center,lTaleil;h,11C 2769 9-16 1 7
110h.Tttr hileelloti Wells.-hi additiou-to sending the fotnt to the address to tca
fie.Boreholedlatlicter:2 above.also subadi one copy,of ibis.fame u'itliiio30 t6ays of cmtiptetiolt Of well .
m. :Nudomitcid to 1hc.follotit•il1z
Divisttru.0f WaterResourc�;Undergman.d Injection Couttvl P*ratu,
Gd,Water level.below protind 5tarfaee; (ft.) 1636 NTail Senice k.entcr,.Rale€gh,XC 27699-1636
Q6c,"Fnr\Valor 5unnh'.&Inimilnn Weis,: In addition to scndieg the forth.to
6e.Outer casing length(if linown)i 5 (ft.) tlWAdress{es);above. also Albtilil-one copy of this fotut within 30 days of
compttaien of well obandnlument'to the count}'heattli'deparinteist of the county
6f.Inter easinwltuhing tcil,-th(if!alter,n): (ft)
*lwrc Abih4owd.
dg,.$rrl.�n lcu{;th(if kuovvn)i10 (ft.) �
Fbmk GAF-34 'Nonh Caroltin Depati mvi of Pm irontnent and N:numl Rcse=cs—Division of Winter ke5ou=s Revised August 2013