Transylvania_Well Abandonment_20221028 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Edward ,�(/ II s Taylor, Jr.
tl V r y y r 7a For Geoprobe/DPT or Closed- oop Geothermal Wells having the same
Well Contractor Name.(or well owmer personally abandoning well on his/her property) well construction/depth,only 1 GW36 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): O.75 (gaL)
Geonetics Corporation FOR WATER SUPPLY WELLS ONLY:
Company Name 7a Type of disinfectant used:
2.Well Construction Permit N: NA
List all applicable well constmenon peranns(La UIC,Coney,State,Yarlance,etc)Ifknorvn
7d.Amount of disinfectant used:
3.Well use(checkwell use):
Water Supply Well: 7e.Sealing materials used(check irE'that apply):
[]Agricultural []Municipal/Public ❑Neat Cement Grout III Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) []Residential Water Supply(single) IN Sand Cement Grout ❑Dry Clay
Olndustrial/Com mercial EIResidential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
0hriludion ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
eMonitoring []Recovery
Injection Well: 71.For each material selected above,provide amount of materials used:
[]Aquifer Recharge []Groundwater Remediation Approx.0.30 cu.ft.bentonite chips
❑Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑Stormwater Dminage Approx.0.30 cu.ft,sand cement
[]Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
[]Geothemud(Closed Loop) []Tracer I
oileothemmal(Heatin Coolio Return) ocher lainunder7 Removed manhole cover and well plug
Measured total well depth'and water level
4.Date well(s)abandoned: 1 O/11/22 poured bentonite chips into annulus of outer&inner casing
Sa.Well location: Poured cement grout into Innereasing and inside manhole,replaced manhole cover
Houck & Sons, Inc NA
Facility/OwnerNama Facility ID#(if applicable) S.Certification:
1321 Ecusta Road, Pisgah Forest, NC EaM,a4-cI W. rays JY. 10/13/22
Physical Address,City,and Zip Signature of Certified Well Contractor of Well Owner Date
Transylvania 8596-58-6089-000 By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
trod that a copy ofthis record has been provided to the well owner.
5b.Latitude and longitude in degreesturinutestseconds or decimal degrees: I 1
(ifwell field,one Iat/long is sufficient) 9.Site diagram or additional well,detalls:.
35.25419 N -82.7001 r-7 W 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.
I
CONSTRUCTION ION DETAILS OF WELL(S)BEING ABANDONED SUBMI�AL INSTRUCTIONS I
AtfadtwellconsbucNon records)ifavai(able.FormulNpleliyeclionarnon-watersupplywells
ONLY mth the same conslracfior✓abmrdoranen;you can submit onejorm l0a For All Wells: Submit this".form within 30 days of completion of well
6a Well IDS:
M W-7 D abandonment to the following:
Division of Water Resotiroes,Information Processing Unit,
6b.Total well depth: 24.4 (ft.) 1617 Mail Service Center,Raleigh,NC 276994617
106.For Iniection.Wens: m addition to sending the form to the address in 10a
6c.Borehole diameter: Unknown (in.) 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: 5.90 (ft.) Division of Water Resources,Underground Nection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
4 inch diameter 10e.For Water Supply&In)ectio Wells: In addition to sending the form to the
6a Outer casing length(if known): (n) address(es)above,also submit one copy of this farm within 30 days of completion
of well abandonment to the county health department of the county where
61.Inner casingttubing length(if known): [Inch ammeter (f.) abandoned.
6g.Screen length(if known): NA (ft.)
Your GW-30 North Carolina Department of Environmental Quality-Division of Water Resources) Revised 2-22-2016

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State Project: R-5763 Houck & Sons, Inc. Property Parcel #083 Seramur
itoring Transylvania County, NC 1321 Ecusta Road Facility I.D. #: N/A E
Pisgah Forest, NC