Buncombe_Well Abandonment_20221118

_n WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-L;06p Geothermal Wells having the same
Well r Name(or well owner personally abandoning well on his/her property) well coastruction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS O]NNLY:
Company Name 7c.Type of disinfectant used: q,
n,`U ✓ `1�`�-1 1
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,Coun),,State,Variance,etc.)iflaeown �
7d.Amount of disinfectant used: a ° !!1
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ❑Sand Cement Grout )4 Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout _ ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity,Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) j Pon •N
4.Date well(s)abandoned: oh—?
t s —
5a.Well location: NOV I (�
Facility/Olvner Name Facility HN(if applicable) r+ N tli-
Ay4ical Address,City,and Zip rgrratur of delfid ell Conhactor or Well Owner D to
OD 0 By signing this form,I hereby certify that the well(s)was(were) abandoned in
ounty Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
N 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.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the some consn•uction/abandonment,you can submit one form.
.• 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: vo 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e Outer casing length(if known): (ft) 10c.For Water Supply&Injection 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
6f.Inner casing/tubing length(if known): (ft.)
abandoned. RECEIVED
6g.Screen length(if known): (ft) AIo`/ a 2022
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources:N C D EQ/DWR Revised 2-22-2016
Central Office

2 N:. / �71moD
s C. e Number:VUEL .�2z�o0�T7 PI
BUNCOMBE COUNTY DEPARTMENT OF HEALTH
ENVIROMENTAL HEALTH SERVICES (828=250-50,16)
c11NELL
CERTIFICATE OF COMPLETION
Applicant/Owner: v76✓ i
Location: A/ Subdivision: Lot:
Drilling Contractor/Compan Cert.
As=Bu11t Diagram(Not to Scale)
J
.Perlrnrt�FOr � •O Single Family �Shared ❑Pu.blic - �Repair � ❑Irrigation j- BAbandonment
Construction Final Well Head.Inspection
Total,.Depth: (ft) Threadless Sample Tap a yes ono ;Hose.Bib o yes o no
Casing Type: 13 PVC ❑Steel Casing.Depth: (ft) Vent ❑yes o no Sanitary Seal o yes.o.no
Diameter ❑6.25" ❑6.0" Purrip Installer: Cert.#
Wt. /Thickness:o SDR 21 o SDR 27 ❑0.185 Pump.Installed Date
Height: (ft) Pump Contractor ID Plate
Static H2O Level: (ft) Well Contractor ID Plate
Yield: (gpm) — Liner Installed Date
GPS Well Abandonment Date D 3 ZZ
Latitude: Longitude: Sealant.Material
Grout Final Inspector
Type: o Neat Cement ❑.Sand Cement. oC.ncrete Date
❑ Bentonite (slurry).(pellets) o5pecialty
Thickness: (in) Depth; (ft) Water Samples Collected By
Date Time
Grout Inspected By:
Date: Comments
Grout.Not Witnessed By Dept. Date
upon final inspection yourwell will meet the North.Carolina well construction standard requirements in accordance:with the North Carolina Administration Code.'ntie 15A
subchapter 2c.Future peogrmance of yourwell with respect to:yield;aesthetic quality,or contamination is not guaranteed:by Buncombe County.The well owner shall.not
place potential sources of groundwater contamination closer to the well than the_separation distanees:specified in 15XNCAC U2C.
Revised 01/16