Buncombe_Well Abandonment_20240617 (4)

WELL ABANDONMENT RECORD For lnlerilel Use ONLY.
This form can be used for single or multiple wells
L Well tantractrir Infornration: WEI.I.ABANDONMENT DETAILS
Rich Lemire 7a.Number of cods berry(abanduned: 1
Wdlt'ouwxkx Nam lot wellowrierp.rsonallsAx3ndontngwellon halter properNI h,w multtf,k o1jeth,n, .w k.n-N<uer ropyh rplis ONV rrrh r♦k• a,A"o,
,',owm,0,A ah,a+Amm,'rir,moot lt9r 1w1Vnl1`,Mw Kim
2593A
'b.Appnninutc vulumt:of pater nmainin> m wcll(v1�O (too
N('w�dlConlrxinrCcnific:aiinn Nnnircr
SAEDACCO FOR WATER SUPPLY N FLLS ON'I.Y:
C•onQnin Name 'c. fy pe of diainfirtaiad used:
L Well Cwtnictiun Pei Ydt 0:,
l isr,dt,gq/IHvAIr arNrmltr 11.P.(uYrYt'.1'r+Nr,J�nWrre Irt/aa4iun,r7c.,,14'm.�
d.Amiwnt ul Jisinfatanl u%cd:
3.well usr(check oAtil uses:
Water Suppl} Well: 7e Scaling material%uvd wheek All that apply!:
CI A_muhural 0%ltmicipa4Pubhoz M Neal Cement Ciniiu M Bcraonitc Chips or Pellets
06cothcmL•il(Hcatinv;'Coohnp SuMINI ❑Rcsicictnu►I Water Supple isingic) ❑ Sand Cement Grout ❑ Dry CLt,,
01►Idustrtal:Conmicicial ❑RL•srdettial Water Supph isharcd) ❑ CommicGrow ❑ DrillCuttinps
❑Irn eon ❑ Spenalh Grout ❑ Gra%cl
Nan-Water Supply Well: t_1 Bentoliite Sourer f]Other(explain udder 7g)
NklointonnL ❑RL•co%crr
Injection Kell: 7f,For each material Klerted ahnre,prosidc ammont of materialsnw-4:
❑Aquifer Recharge ❑Cirourdsvaler Rentedialtott Neat Cem. :941b ,Wtr:6gal. Sand Cem. :lb ,Wtr:gal.
❑Agmfer Storage and Recos cry ❑Saluurt. Barrier
❑Aquifer'hesl ❑Slomlwalcr Drainage PORTLAND /BENTONITE POWER/BENTO',
DExpettmernal I cschnoloK% ❑Subsidicme Cotarol 7R•Prrii like a brief olmription of the abandomincnt pmceilure:
❑Geethennal(Closed l"pf L1Tiacer
1Heatin 'Conlin Retum) I(Other(c� sin under 7 )
BENTONITE PELLETS SLOW RELEASE TO TOP O-F WATER,TEIEM TREMMIE
OGeoth:rtnl --
GROUTED TOP OF WATER TO SURFACE.
,i-Date well(-)abandoned: 5-14-2024
Sa.Wto IiKatioa:
FORMER ALLIANCE CAROLINA TOOL/MOLD CO. iON
S.C'ertirwation:
Facitth(1nriCrNamc r•.,cailymN(irapplicabte► itD ka01i: ,ii4rl r+-e.:,yty►�,�
UM
125 Glenn Bridge Rd. Arden, NC 28704 DificL,JW/2024
Wdress.C1h.aid Zip SrpMitR of-.»!fled Wta Cnmxmr ar Well 0%act Dote
BUNCOMBE By"gmgg fhes,)6rm• I hereby cergly Am the well(s) was tweret rahlunfnned or
t.,.ua1 1',i-1kk-Aitx:ilh!iiN, o acecordaw-cwAIJAWACO2C.0100or C.02001E'ellConshwctionst►mclrm/K
and shed a caps of&ts reicord lea beers provided to the well owner.
Sh•Latitude and longitude in rkRrcrslminutrc scronds or decimal degi-evs:
!d ucn I-Lid moo:Lot Gwg r,uffj,tc ri 9•Site diagram wadditional viell defail9:
You brio use the be&of this page to prm ide addinoital well site details or well
N W' abatitkwntent details. You titan also aitach additional pages if necessan.
tONSTRUIEMON DETAILS OF W'ELLISi REIN(:ABANDONED SUBMITTAL.INSTRUCTIONS
... �:r..l7rudnnt nennba{l oawiaMh•. hew mulUplr rn/re txm ru inn•»d1.r wfq•i1
r, r> •il,r1k•,anir arwuUri►fxgt,rf4ankMlMenl.1UY can arhnu!core JuAn. Isla. For all Wells: Subtrut this form imflun 10 days of completion of well
-6 ibaridonmeni to the following
Disision of Water Rcw-urres,Information Processing l nit.
38
1617 Mail Seesice Center,Raleigh.N('2 769)-1 6 1 7
i,b. I.ot,►I well rkpdc tft.1
10b.For infection Wells: In adduicm to beading lire form to the:ddicss ua lua
abuse. also subnut one copy of sous form widrin Yl dins of completion of well
t,c.Ro,rehodr diameter:2 tin.) abandomiteni to the tollowntc,
Di►ision or Water Revource%.I nders;niund Injeection Cournil Pn1l,ram.
i>d.\\stir!es el hrhiw L+rrlund siirtaee: 28 (ft.1 1636 Mail Sinice(enter,Raleigh,N('276"-1636
Ilk. For Water Suoitls & Ini irdiun Wells: In addimm to sending ilk foml to
tic.Outer aa.in.lcn'-th tifknowa): (ft•► the address(esi abote. also submit one cops of this fora within Ill dins of
;ouiplction of sell abarriomn:nt to the coumo, health rlepartinetn of ibc county
ss I�rc atxrndoilcd
I&Inner length!if lcnnwn):
i.g.scrccn Icngrh of hriawnI: (ft.)
i I 'A- - Noah Caroli►n Dcpanincei of Ent irwinteta aid Nara►rat Resources Di%iston of Water Resoiuecs Res iced Attpusi 201I