Transylvania_Well Abandonment_20240903 (4)

VkLL ABANDONMENT RECORD For Imcrmsl Use ONLY
This fomt can be used for sii*k or multiple wells
1.Well Contractor Information: WELL ABAiVQONMENT DFTAll%
Rich Lemire 7s.Nemberoffrells being abandoned: 1
!Ifotiratortsft(or will o*WN-twu2ily*andaningxellonlnIA"pmpm) Fto n+alnAte lufvrur► cw moo-axx.r swrh wells OIVtY WA .sYe r6aee
2593A
NC wen CnremKtor CanifKation Number7b.Approximate%via le of water renuining in ritll(x)*ONE f1ral•1
SAEDACCO FOR WATER SUPPLY WELLS ONLY.
Covvmr Na►nc 7c.Type of dialsfecust used:
2.Well Construction Pernik 0:
LW ell,rppkvblevellp"Win a r f ft*,Saw,Itirla►rca INJeakwX ror.t ewer 7d.Amoest of disinfectant used:
3.Well use(check well use):
Water Suppy Weil: 7e.Sealing nuteriats aacd(cbeck all that apply):
DAricuhurei OhlunicipritMbliC Ili Nm Cement Grout 0 berroniteGips arPetkt
QGeolh ratat(HeatiaptCooNng Supply) ORcsidcrtiai Water Supply(angle) C3 Surd Ce""Groot O Dry Clay
❑b dustrial/Comomiat ❑RcsWraial Water Supply(sharW) C3 Concrete Grout ❑Doll CWHOP
1311nigation C3 Speaalty t.MW ❑Ck"A
Nna-Water Sapply Wen: Ci 8sutomic Slurry 0 Other texplim unit 711)
®hdanitoring OR=ovett'
Injection well. W..Foreachmaterial selected al*iv.prnride amount of matc#iabunds
OAquiferRecharge OGtouodwaterRemediation Neat Cem.:3761b ,Wtr:24cjal. Sand Cem.:lb ,Wtr:gal.
OAgtdfer Stoew and Recoti try OSalinity Hamer --
0At oKa Test ostorai afar Drainage --
Ofterimental Technology MubsidetlCe Control "c.Frm idc a brief description of the abandonment prncedurv:
0Gcothernml(Closed Loop) OTracer
aGeothermalOfenti Voohm£Retum) O011ter(ex inutder7 ) TREMIE GROUTED FROM BOTTOM TO TOP; 45' ALSO REMOVED ALL
CASING ABOVE ROCK AT 20' BELOW SURFACE.
4.Date weW0)abandQned• 8-13-2 0 2 4 -
5a.Weld hrcation:
WOODRUFF LANDFILL J % 2024
( HOph�1b1S) �•Cel'tifleatiOA:.
FaCiMtlOMintr�.inx
500 Howell Rd. Brevard, NC 28712 C/�.e/lrnN_.ti J [', B/1j/202 '
Plnr'sical Address.City,mad Zip Sig►nttlne ttl .=:idksl Will C4r9tactaror 1Yed taCr Aare
TRANSYLVANIA hI,atijtrtiW NKr fvw4 I hemb}cerrrfy thw the we#pis was fwoml ahrvaloned in
Cc nun 1'atecl IdLour ration No.(PIN) oct rrruYwr 1r*t.1A.NrAC 02t:..0100 or 2C VW WWI C vnv wrnvn.9ra")rdr
mil lhwe a cvyry of lhrs re,curd I*tr eeem pr orydCat to tlir weft rnrmr.
Sk Latitude and longitude in dcovestminatesfsecands or decimal decrees:
tifws•ll OcK om lat•inttg h sulFicwrsl 9.Site diagram or additional Nell deta t:
You ttbgr at the bad of this page to provide additiorml well ale details or rcell
N W abandorntt u detaik You Its also attach additional popes if tteces w .
COMMUCTION DETAILS OF WELDS)BEING ABANDONED r UOMMAi.iNSTRUCTION4
A(tdaF rrc11 era�urWlrNr rrsuufix+F(m^atlubk h"cr Mmft�ptr e+7re•Iraa nv nna-»wxr upph• -
»elb ONLY wrd,the a�cwceu+renox�wnab�z�.,iurcanaih«utowf-- loa. For All Welk: Submit Chas form within 30 da)s of cornpiction at well
6s.Well 1DN:NW-13 abandotrrmcul to the foilowiw
Dbiaina of Water Reaa,urrea,Information Proccising Unit.
6h.Total arll depth: 45 (ft.)
1617 Mail Scnice Ccoter.Raleigh.NC 27699-1617
19b.Fb IsItgW Wells: Ito addition to seadinig the torte 10 the address in 10a
bc.&rrrinrlc diameter:a aboer.also submit out copy of this form within 30 days of completion of srdi
(to•) abi n lonment to due followilw,
Dkislon of Water Resources,t'ndcrurrwtnd Injection Control Program.
t.d.%k Ater lce cl below ground surf scc: (ft.) 1636 Mail Scnicc Center,Halcigh.?NC Z76"-1636
Ile.For WateraS,Bouly& Inlccfirrn Welip In addition to sending the form to
6e.Orfescasinc,Ic•n-.th Iif hnewa): 20 tft) the addressfes) above. also submit one cope of this:fbvm within t0 days of
completion of all aba danntent to the comNy health depanmed of the County
6t.hIllr•eadughubing demo(If fmonO): tft.l where ebandoacd.
tg Sty It"o(it known): (tt)
Fora►aw-)i NaAh Carofnn Dcpartrrtl d of fsoiroamcnt aW Nararal ResouIes-Di►ision of WSW kCWUX'c•s Rc%*W Auptst 20B