Buncombe_Well Abandonment_20220907

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JOHNNY BURR 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) hor nuehiple injection or non-rDaler supply ive/tv 01VU is-oh the scene
cunsrnrclion aburalnranew.you can subnot one lirrnr.
A - 3098
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2'0 (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
/.c+t all applicable well cnrrsln viun permits(i.e.County,S'lale,Voriunce,etc.)iI knoum 7d.Amount of disinfectant used
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(checkall that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: R1 Bentonite Slurry ❑ Other(explain under 7g)
O Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 2.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description oCthe abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
jl
07/21/22 Ell
_ :
4.Date well(s)abandoned: C`p n Y ,En,2
�1
Sa.Well location:
ASHEVILLE AIRPORT
FaciligdO+vner Name Facility IDH(ifapplicable)
8.Certification:
27S WRIGHT BROTHERS WAY ASHEVILLE 28732 � 08/30/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
BUNCOMBE By signing this form. l hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance frith 15A NCAC 02C.0l00 or 2C.0200 Well Construcrion Standards
and that a cop),of this record has been provided to the well owner.
>b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 9.Site diagram or additional well details:
350 25' 31.70" N 820 32' 26.65" 4` You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Anode well construction record(s)ifarailable. hor ruulople injection or non-realer supply
%•ells ONLY with the same con.sirac•tionahandonrnenl,you cost subrnil one fr,rnr. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
MW-2A abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
15.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the torn to the address in l0a
2 0 above, also submit one copy of tliis form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
3.5 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
loc. For Water Supply& Infection Wells: In addition to sending the torn to
6e.Outer casing length(if known): (ft.) the 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 c01.1111y
where abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form G W-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2011