Buncombe_Well Abandonment_20240617 (7)

WELL ABANDONMENT RECORD rartrntriml I 0,41 t
This form can be used for single or mdliple wells
t.%%ell Contractor Infornutios: K'F.LI.ABAVDONFIEN•T DETAILS
Rich Lemire 7a.Numberoftsd1%being!abandoned:
1
Well e'otarackm Nang rut well uwtnY petsonallt alu"Innig well on lnsrlter propem t F:r mnlnpir otter tree. it wm-Wurer itytpfi well. O.M Wnh OW ,ante
rsairrnrr mm.7h,nirlrntm,,mt.reim t ur swltmlt ate Faint
2593A
-b_ \lgirotimeic tolurtw•of water remaining in ssel11s1�OME 1><al.l
NC Wc11 Ccimntdnr Ccnificalinn Nnnbtrr
SAEDACCO I.OR%%ATE R SUPPI.Y WELLS ONL :
Canipnm Name _C Type of did wed:—
2.Wdl Cwtttictina!erne t A:,
lw alit mµryalkvb/r wrU lrrmiir nee.t inn V1.SHMe.!dnrr.rcr lrryrrtum,err.t tlkntare 74L Amosat of disinketmd msed:
J.WdI use(chcch w ell use):
Water Supple Well: 7e.Sealing material.used(check all that apple):
❑Apricnhural ❑MtmtcgxAPubhc 9 Neat Cement Cirotu 00 Rcntonitc Chips or Pcllctc
O(ieothcrtnal(Ncanng-Vooling Suppivi ❑Restdcmial Water Stipph Isinglcl ❑ Sated(•entire Grout ❑ Dn CUN
01dustnal:Commcrcial 011midetuial Water Snpply ishared) ❑ Concrete Grout ❑ Drill Cutbnp
❑Inn wrm ❑ Specials} Grout ❑ Gravel
Nos-Water Supply Well: I 1 Bedomte Slum 11 Other 4c\plain under 7g)
EMomlonng ❑Rrcotcn
Injection Well: 7f,For each material wlreted abnyr,provide amount of materials awl:
❑Aquifer Recharge OGroundwaler Renrednattal Neat Cem.:941b ,Wtr:6gal. Sand Cem. :lb ,Wtr:gal.
❑Agtukr Storage aid Reco%cm OSaluut% Barnet
13A4infaTca ❑StornmalcrDratnagc _—_ PORTLAND /BENTONITE POWER/BENTOI
I7E\pc"nwnwi Techtwlotn Mubsadamc Control -..term ide s brief description of the shantiinment procedure:
OGeolhemial(Closed 1,00pt OTracer
BENTONITE PELLETS SLOW RELEASE TO TOP OF WATER,TBEM TREMMIE
OGootbetmsl(Hati 'Caolin Return) f]Otlrer4 win atelier 7 )
GROUTED TOP OF WATER TO SURFACE.
1-Date wrllfsl abandoned:
5-14-2024
ia."ell location:
FORMER ALLIANCE CAROLINA TOOL/MOLD CO. lTtt�d.'7Csii.1(F.3 1o'�.t.4rtta'�a
r.wilm CrwrterName Facility IQN(ifappliabkl 8.Cedffkadea: D'yl'QA"
125 Glenn Bridge Rd. Arden, NC 28704 _.PiiMt�-tom 5/19/2024
Ph,sic:tl \ddress.Cut.aid Zip SytWiNitof. :iiW,i DCnNgiCbarorWC1-10 r W r Dolt
BUNCOMBE R'sigiung this JFxm, I hereby ceiej(y dwu dice well(s)was tberet ahamlwd in
r n,n 1`.tncl lrkm,fr.,lrm No.(PIN) a"o►tkmk-r with IJA MCA OSC.0100 or X O:N10 IfW1 ConsAYtcnon StanAwds
and tha a cep,ajthis record hoe been provided to the well owner.
Sh.latitude and iungiruile in dervrslminutrar,cconds or decimal degrees:
o t,d:1x1d air Lit.k,tigi,.uiticxitl 9,Site dirgiramor additional well dealils•
You nun use lire back of this page:to provide additional sell site Mils or hell
N W' abatdonntem details. You rim also attach additional litages if necessan.
CONSTRII(MON DETAILS OF W'ELUS1 BEING ABANDONED S1.7111NIMAl,INSTRUCTIONS
Alikuh Well.nmrtrnClnue nararrha+N atuikai!k. Pew mnQiple ugectian rr rem-tauter smWi
welkONLIr with die a rmtrawmtretrrwur abontkxmenl.iw can=hmil rmtr Name 10a. For All Wets: Suhnmt Iht: form within z0 days of rnmpiction of well
64.W'cll ID91:MW-4 ibandommcru to the following
Division of Water Rmijurcr,Information Proccsaing trait,
nth, tenet ell de
luh: 35.6 1617 Mail Scnice Center,Raleigh.NC'2 7699-1 6 1 7
' w IftJ
Rib.For IsieeNos Wells: In addition to sendute the fomr to tic AtItess m loa
abutc_ also submit one cope of this form tsrlbnt ;0&m of Completion of tell
nc. Rmmrrbtdc di:uut Ice:2 lin.l abatdonntem fo the followuu,
27 3 Division of Water Resources,Cndetimiound Injection(onind ProgramSoli.\\rice level hrinw .ry.und wrfacr (h.1 1636 Mail Service Center.Raleigh,N('276"-I(i36
lac, For Water Su mlv At Ink-cl on Wells: In addition to stinrdmg the form to
be.Outer ca,inj!k-u-_nh of knoai n): (ft.) the addwssiC,i abure. also submit one cop% of this font within All days of
completion of ttell abandnmm nit to the.ounh health departmera of the comb
wiicrc abandoned
W.Inner ca,m_itubin_Ien_Kh cif I.nnw n is (fl.)
I.t:,Screen length rein knoll n c
ForinGW-itr Noah Carol ur ititcrofEntiontw:ititdNaiumlRetiames-DnisionofWaierResoux" k%tied AugussN)I