Transylvania_Well Abandonment_20221028

WELL ABANDONMENT RECORD For lmemal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Edward Wyllys Taylor, Jr. 7a For Geoprobe/DPr or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owver personally abandoning well on his(her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 2440-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.4 (guL)
Geonetics Corporation FOR WATER SUPPLY WELLSONLY:
CompmyNama '
7-Well Construction Permit#:
NA 7c Type of disinfectant used:
List all applicable well comhuction permits(Id VIC,Comity,Sane,Variance,eta)orknoon
7d.Amount of disinfectant used:.
3.Well use(checkwell use):
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Water Supply Well: 7e.Sealing materials used(check all that apply):
OAgaeultmal OMunicipaVPubkc ❑Neat Cement Grout a Bentonite Chips or Pellets
OGeothermal(Hesting(Cooling Supply) OResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
OlndustnaliCommercial OResidential Water Supply(sham) ❑ Concrete Grout ❑Drill Cuttings
01rrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ,O Other(explain under 7g)
Emonitoring ORecovery
Injection Well: 711 For each material selected above,provide amount of materials used:
OAquifer Recharge OGroundwater Remediation Approx.0.39 cu.ft.bentonite chips
OAquifer Storage and Recovery OSalinity Barrier
OAquifer Test ❑Stormwater Draiunge
OExperimental Technology OSubsideace Control 7g,Provide a brief description of the abandonment procedure:
OGeathermal(Closed Loop) OTrncer Removed manhole cover�and well plug
O m n Geotheral(Hen Olin Retum) oOther(explain under 7 )
Measured total well depth and water level
4.Date well(s)abandoned: 1 O/11/22 Poured bentonite chips into pipe and manhole
5a.wen location: Hydrated bentonite chips hydrated and replaced manhole cover
Shamsuddin N.Gillani Property 00-35046
Facility/OwnmName, Facility WO(ifapplimbie) &Certification:
1591 Old Hendersonville Hwy, Pisgah Forest, NC Edwcwd.W. Taylor,Jr 10/13/22
Physical Address,City,and Zip Signature of Certified Well Cormactor of Wen Guyer Data
Transylvania 8596-57-4988-000 1
By signing this form,I hereby certify that the well(s) war (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and Utat a copy ofthis record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
Ofwell field ovatat/long is sutEciem) 9.Site diagram or additional well details:
35.25418 N —82.70048 W You may use the back of this page to provide additional well site details or well
abandonment details. You my also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS i
Aaach well conslrueaon records)brmallabla FormulapleWeehmornon-watersupplywel6
OAZYoulr the sane construellonlabaadonaerq you can subnatonefomr l0a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• M W 3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth: 1`�C•O (it) 1617 Mail Service Center,Raleigh,NC 276994617
10h.For Iniecton Wells: In addition to sending the form to the address in i0a
6c.Borehole diameter. unknown Ors.) abandonment
also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: . 6.42 tin) Division of Water Resources,Underground Injection Control Program,
1636 Man Service&nter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA 00 10e.For Water Suonly 8eInjection Wells. In addition to sending the form to 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 county where
6L Inner casingltubing length(if known): NA (ft.) abandoned.
6g.Screen length Of known): NA (li)
From GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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