Buncombe_Well Abandonment_20220930

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
\f.e%Q`'1 i�a AnJ 7a.For Ge6probe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
301 ?-1 - A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1•S6 (gal.)
f 212 L-N Vt Ro�J m`tirn�, S FOR WATER SUPPLY WELLS ONLY:
Company Name
-e /� 7c.Type of disinfectant used:
2.Well Construction nstruction Permit#: IV 1 A
List all applicable well construction permits(i.e. UIC,County,State. Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well usle(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public Neat Cement Grout ❑Bentonite Chips or Pellets
❑GeotheI al(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industri IlIl/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑lrri atioh s G "4 ❑ Specialty Grout ❑Gravel
Non-Water Supply .e s� ❑ Bentonite Slurry ❑Other(explain under 7g)
R Monito ng - -ecovery
Injection Well: ' 7f.For each material selected above,provide amount of materials used:
❑Aquifer Rechar e DGro ndwater Remediation S I r y,/p-`E(�
�Int;yfl�>�€ir�n �1tMi GA1100-a Or
❑Aquifer Storage and Recov;"ai. Qc( ❑$alinity Barrier
1 i3a
❑Aquifer Test ❑Stormwater Drainage A( e0 r- PbrVr e.,w,'�, C-6✓n arJ T-
DExperin ental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer _
❑Geothe al(Heating/Cooling.Refum) ❑Other(explain under 7g) Cyt.)C1 ETE W C 11 PA b A&);' , \/AU(- 12cY► WOO
4.Date wells)abandoned:
r� ! T1Z&Ale. 2,96 PI.�,Qib 1 _b 80-Cror►1 of \hJG L--
4.Date wells)abandoned: t - a 1- Ot�
EAT CaMCO 6"dD VJEII 62 0M 60-morn 1f0 i 0P
J 5a.Well(location:
'ro P t)V 1 L. AN t--4 G 2ASS 5 t:cr p oN J;�t2FiP►C.t<
9ey'rL o"I 5 l 146-, sP=;-t 00-o-CDDCC0
Facility/Omer Name Facility ID#(ifapplicable) 8.Certification: Q
Io3 nlc�, LEI�Es �2 �II�Nw•4y. Asl�vtl� ZIAJ
Physical A Indr-ess,City,and Zip Signature of Certified Well Contractor of Well Owner Date
rs7 U N�=d tM b L= �(�aA?g329 a"m By signing this_form, /hereby certify that the weR(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 ojthis record has been provided to the well owner.
Sb.Latit de and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell I field,one lat/long is sufficient) 9.Site diagram or additional well details:
3/ n
.7.' rd ��O N • ��s J W You may use the back of this page to provide additional well site details or well
y / abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attachmet,constructionrecords)ifavailable. For multiple hyection or non-crater supply x-ells
ONLY with the.came construc•tion/abandnnment•you can submit ane form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well)D#: LAJ CO abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:. • 5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
tub.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (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 3 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
6e.Outer casingif known): 10c.For Water Supply&Injection Wells: In addition to sendingthe form to the
length g ( ) 3 a' s (ft.) address(es)above,also submit one copy,of this form within 30 days of completion
N 1 f F
J �p{ (ft.) abandoned.
andoned.well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): ( )
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016