Buncombe_Well Abandonment_20230706

WELL ABANDONMENT RECORD P.,r „!roar 1 u ONI
• This font on be used for single or multiple%eUs
1.Well Contractor Information: `�� WELL,ABANDONMENT DETAILS
Stefan Smith 7a,Number of wells being abandoned: 3
WeItCuunraaof Name(Of wellowtt.IpOW"!,alsatmdnftingwetlonliearlrrptrpcittI F(w wirloplc oijetir„r or ra,a-wafeM motipt walls ONLI rub Nx, uattt
rvrlt+trnch,Ht,tl,amhnmrrir,ir�a tvtn rahmtt ate hunt
3576A 'b 1l,prn�int.ttrtitdumcufwatctrrmaininl;inrrll(s1?1 {Ball
WC Well ComnacforCettifiatioo Nnrnber
SAEDACCO Inc FOR N A'I ER SUPPLY WELLS ONLY:
('onipart.Name 7in Type of dial 6 nt need:
2.Well Censtrudlen Perwit
Lit,r edl tiltro&able well lrr,reEr n.e.Cuntav,,%Lw.1 din rgmNtticyr rt �(Cttt,r
7&Amnon of 411dtt[ectM weA:
3.Well use(chndc well use):
Water Suppli Well: O 7e,Sealing materials used(check all that apply):
❑Agncuhural ❑tihinicipal:l'ublic ❑ Neat Cement Grout 5a 9ennionite Chips or Pellets
t ❑ Sand Centett Grout ❑ Un Clay
❑(icathcrmnl(Hcatinl Caohng Sirppls i ❑Rtr1(ddtftialVafer fu 1�sr.
rat❑I ❑Concrete Germ ❑ Drill Cuttings
nmdttstriaL�Commcrcial ❑Rtdcm csptal t'�;titcr�uppf, ishat'rd1
❑Itri •tion ❑ Specialty Grote ❑ Gnarl
Non-Water Supply Well: ❑Bentotnte Slum f_l lather oloplaiti ttoder 1g)
mhlontlonne ❑Rcco%rn
Injnctinn Well: X For each material tielected Ah-t%e.ptrie idc anitumt of materials used:
❑Aqutfcr Recharge ❑Groundwater Remedudicin
❑Aquikr Storage and Recorn'en ❑Snlimty Barrier --
❑AquiferTeat ❑StomnsaterDrainage Bentonite.:21b ,Wtr:gal.
❑Etipertmennah Tecltuolog ❑Subudience Control Tr,Pntvide a brief description tit the abantiontncnt prucetlum
OGeothernud(Closed Loop OTracer
Pulled DPT tooling and :backfilled boring v/ hydrated
❑Geolhemtal(Head 'Coolm:,P,itirn) ❑O#kr{ex �ainunder ► —
bentonite chips
L D:m nett.!abantlttnctt 12 June 23
*a.11 e11 lucAtipit:
Facilgl t)wacr N:uoc lrxility IDN(if applicable I
e.Cet1f11cadon:
144 Tunnel Rd. Asheville, NC 28805 6/16/2023
Pin sieal Address.Cis,.Aid Zip �' sae -.CCndW WtH C osagicmr ter W CU Clear Dow
Buncombe Ifs•.sigmirK thcs J6rm, 1 hereby crrq#Nat the well(s) was(were/ a!rmukmed m
Counts I xt cl W:„t,ftiL:iiutu No.(PINT fucvrrhrttt•e wrdr 15.4 ArAC 02C,0100 or X VM Well C arsfrtrchon arradrrrds
and drat a cmyvp of&is record has hem provided to the well owner.
ih,lAtilude and Inngitudt•in or decimal degrrcx
iifwcll fs;W,otr Erelong u titdrscoctal 9.Site diagram or additional well details:
You tnat tr a the back of tins page to prrn ide additional%tell site details or well
35.590819 N 82.529824 W abatdonnmem details. You inay also attach acWitenul pages if ntecsssan.
CONSTRUCTION DE'TAILN OF WE:LIAS►HEING ABANDONED SUBMITTAL.INSTRUCTIONS
Atiuch well CnnrtruC'raMt n-curibv y avialdik. /'t.,r MaJerplc'oyes eor(o wti-ale'r sitlll]lt'
welts ONLY trtth de name ewcsNstrrxat aAutnekuanntt.iew cart suhnol are Firm. loa. For All Well: Submil this form %!thin 30 days of completion of well
abandonment to the fallowing:
61L Will ID#-TMW'1
Diviatiau of Water Rnourcec,Information Pnnccssirng 1'oit,
ieD.'fatal Dell depth; 10
1617 Mail Senicr Center,Raleigh.NC'2 7699-1 6 1 7
(ft)
10b. Fur lialectlas W'eils: In addition to sending like form to the address iii Via
6c BrtreMde diameter;2.25 aboNe. also satimil one CUD\' of this form within 30 days of conlp lion of ttell
do.) abandonment to the following
Diotislon of Water Remarries,Undergirmad Injection Contrtil Program.
6d.Water km el hehiw ground surfaer: fft) 1636 Mail ticnice Center,Raleigh,NC 27699-1636
roc.For Water Stw ul. Ns:& Iniection We In addition to sending the form to
6e Outer casing length iif taro%nt: ( ) the address(es) aboee. also submit one coin of this form within 30 dimys of
completion of well abandonment to the county health dcpannictt of the county
6f.holler c asing:'tubing k nLKh(if lmown l: (lti) w Bete abnitdmicd
61t.Scorn Ierigth(if(uttiwn1:4 M)
Fart GW-10 NOnhCtitoYns Departurro of Em nonmcnt and Nowal Resotrees-Di.taunt t,f w;it,.r V:­onfens Ik.6cd Ammst 21m13