Buncombe_Well Abandonment_20240116

WELL ABANDONMENT RECORD For lmeraalI ONLY:
1.Wen contractor Information: WELL ABANDONMENT DETAII%S'
(I T F �+CZ,a G 1 S 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well ContucrarName(or well ownerpereonany abandoning wen on bie/har property) well constraction/depth,only I GW 30 is needed. Indicate TOTAL NUMBER of
- wells abandoned: ---
arGa`-'�
NC Well Conoador Certification Number 7b.Approximate volume of watee remaining inwell(s): (gal.)
FOR WATER SUPPLY WELLS ONLY-
Cmpany Name lc.Type of disinfectant used:
k
2.Well Construction Permit#:
List allapplicable,w.Ucom&uctionpmdb(i.e.EUC Cormfy,&a14 14mimmm eta)ljbrawn
7d.Amount of disinfectant used:'
3.Wen use(check well use):
Water Supply Well: 7e.Searing materials used(check'all that ap
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout otentonite Chips or Pellets
QGeoUrennal(Heating/Cooling Supply) ❑Residential water supply(single) ❑Sand cement Grout ❑Dry Clay
❑lndusWeltCommervial ❑Residential Water Supply(abated) •❑Concrete Gaut ❑Drill Cuttings
[3hrigation ❑Specialty Grout ❑Gravel
No ter Supply We1L• s 'Of Bentonite Slurry ❑Other(explain under 7g)
Mu0nitoring ❑Recovery
Injection Well: 7E For each material selected above,provide&meant of materials used:
❑Aquifer Recharge ❑Groundwater Remediation -
�❑Aquifer Storage and Recovery 17Salinity Barhiec.
Test ❑Sto>mtwater Ihainage .
C]Expe<i sal Technology ❑Subsidence Connol 7g.Provide a brief on of the ddnnent procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal Cooling Return ❑Otter lain under 7 ,
Alm � ,an
4.Date well(s)abandoned: vLJ
Sa.Well location: JA N 16 2074
F �ow acme © S Fw t ]D#(ifMlicable) e.Vertifi one I I ,- :iiD
5 ;kS
Address,City, .Zip S' of C Contactor or Well Owner
By signing this form,I hereby cero that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C'0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the weU owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattiong is saScie O 1 ) 9.Site diagram or additional well details:
`7J 3 -I /' W You may use the back of thin page to convicts additional well site details or well
t abandonment details. You may also attach additional pages ifnecessary.
CONSTRIICTIORDETAILS OF WELL(Sl BEING ABANDONED �rtpl -pAL IIYS1gIICTIONS
Atmahw ilconsructionrecord(k)(favaliabk For muidplebdecdonornmr--aa-:w,pp1Y-as
0NLYwuh theaane cons&u`ctiabn/abm dm_wie4 you can submit-ejosm 102.For All Wells: Submit this'foffi within 30 days-of completion of well
6a.Well ID#: 'M w abandonment to the following.
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1 (ft) 1617 Mall Service Center,Raleigh,NC 27699-1617
10b.For blecdou Wens: In addon to sending the form to the address in 10a
6c.Borehole diameter: (0 (in.) 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: (g,) Division of Water Resources,Underground Injection Control Program,
1636 Man Service Center,Raleigh,NC 27699-1636
r I known): "— Xt.) loc.For Water Snnuly&Inlectil nVells: In addition to sending the form to the
6e.l7utti (Y ) 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
6L Inner casing/tubing length(if known): (@,) abandoned
6g.Screen length(if known): 51 �
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resume i Revised 2 22-2016