Buncombe_Well Abandonment_20221205

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WELL ABANDONMENT RECORD For Internal Use ONLY: i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jeffrey Grant 7a.For Geoprobe/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 1 GW 30;is needed. Indicate TOTAL NUMBER of
4328-B wells abandoned: -
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): .2 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
WM0100530
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout IN 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
❑Irrigation ❑ Specialty Grout ❑Gravel
- -Non-WaterSu 1 Well:-- - - -- -- --- -
PP Y --❑-BentoniFe Slurry- - - T--"❑-OtheP explain-undei7g)'-'-
eMonitoring ❑Recovery
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Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite 20 pounds
❑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) Fill borehole with bentonite.
4.Date well(s)abandoned: 1 1-14-22 }
5a.Well location: Dr C .'1 2027
Winter Bell Company V
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: f rOcr;0Zin.Urg;l
17 Truckers Place, Asheville, 28805 "'
L,�i�t-� 11-14-22
Physical Address,City,and Zip Signal o(964fled ell Vattractor of Well Owner Date
Buncombe 965863432 By signing this form, I hereby ce trfy that the ivell(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has ben provided to the well owner.
'
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well l details:
35.577350 N 82.510519 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
Anach well construction record(s)ifarailable. For multiple it lection or non-water supply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: GW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 19 (ft.) 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: 1.5 (in,) above,also submit one copy of this,form within 30 days of completion of well
abandonment to the following:
15.33 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) ,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 15 (ft.) 10c.For Water Supply&Iniecti i n Wells. In addition to sending the form to the
address(es)above,also submit onelcopy of this form within 30 days of completion
of well abandonment to the county health department of the county where
611 Inner casing/tubing length(if known): (ft.) abandoned.
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6g.Screen length(if known): 4
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jeffrey Grant 7a.For Geoprobe/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 E30 rs needed. Indicate TOTAL NUMBER of
4328-B wells abandoned:c�a
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '2 (gal.)
IJG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
WM0100530 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout S 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 I ❑ Gravel
- -Non-Water Su 1 -Well:-'--- —--—- - ----
PP Y —-❑-BentonitirSlurty- —-�- —Q-Other(explain-nnder7gJ---
IlMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite 40 pounds
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Fill borehole with bentonite.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
r-�
4.Date well(s)abandoned: 1 1-14-22
5a.Well location: He
Winter Bell Company In;,,s,-,t air ?rc<cz yrg Ur.il
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: sr3 'Q/30I^
17 Truckers Place, Asheville, 28805 11-14-22
Physical Address,City,and Zip Signatureo(/enki WelhVouttVtor or Well Owner Date
Buncombe 965863432 11
By signing this form, I hereby certify,
r that the ivell(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 of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.577350 N 82.510519 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-water supply wells
ONLY with the same cmisinrclion/abandonnrent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: GW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:
20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2.25 (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: 16.78 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
16 (ft.) 10c.For Water Sunaly&Iniectidn 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
611 Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 4 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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� i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAIIILS
Jeffrey Grant 7a.For Geoprobe/DPT or ClosediLoop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:ore
4328-B
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '2 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
WM0100530 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout a 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:— -❑-Bentonite Slant' - —❑-Other-(explain-under-7g)
FlMonitoring ❑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 ❑StormwaterDrainage Bentonite 40 pounds
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Fill borehole with bentonite.
❑Geothermal(Heating/Cooling ReReturn) ❑Other(explain under 7g)
'eel
4.Date well(s)abandoned: 1 1-14-22
nr c 4 5 2022
Sa.Well location:
Winter Bell Company -` �r,,�t �, *� �Unit
sriifie�ij�
Facility/Owner Name Facility ID#(ifapplicable) II.Certification:
17 Truckers Place, Asheville, 28805 .9te�f� 11-14-22
Physical Address,City,and Zip Sign ne Krertifie&VeIPContractor or;Well Owner Date
Buncombe 965863432
By signing this form, I hereby ceriify�that the ivell(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0,100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.577350 N 82.510519 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
Altach well construction record(s)ifavailable.For multiple h jection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: GW-3 abandonment to the following: ,
Division of water Resources,Information Processing Unit,
6b.Total well depth: 22.5 (ft.) 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: 2.25 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I
Gd.Water level below ground surface.
20.48 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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18.5 1Oc.For Water Su
aaly&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the coutity,health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 4
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016