Henderson_Well Abandonment_20230602

WELL ABANDONMENT RECORD � For ItaemilUwMY:
This farm cast be used for single or muhipie wv lls `\,
1.Well Contractor information. \,-X WELL ABANtlnNMEVT DETAILS
Stefan Smith 7a,Number of w0ls being olmnduned: 1
WellCCramciarNnnte(wswllo56mNFW'Itally,aharnlnrtinettetl.ouN8 U erpraperry) Fcw rem[OpL lnlee8•wr a. rr ra-srah'r sigrd!h- aelis ONLY %wh the s[mie
rxrravrnrcflrxlr�o,rrinnnn2t6 self!c'rUP,5A1N11lf rNlu*f1fAl•
3576A
NC Well Cautragi rtmili=tiou Nun•bcr
7b.ApprMhurte volume of auto.t•�emaining in
ONLY:
SAEDACCO Inc FOR WATER.SUPPi,Y WET-L.5
Company Name, 7e,Type of disinfectant used,N/A
2.Well Construction Permit a:
LO i,11;1pp/krl0dr troll perlirite lie_Cwr9il.kum.J'aharwe.brfedim-e1cl yllf nsr! 7d.Amonnl of disinfectitut used:
3.Well u. (clrerl.lVell use):
Water Supply Well; 7e.Scaling mutcrials uml(cheese all that apply-):
gAgti nitttG3t 13municip;tmilitic 6d Nast Comets[Grout 11 13e1140niW Chips or Rllcts.
Micathcniml(Hcatin,�.'Ceoling 5upply) Milesidontial Water Supply(singlc) El Sind Centeru Grout ❑ Urn'CLty
❑hidustdal;Commcicial ❑llesidential Water Supph•(slmrcd) ❑Conc[nte Grant �,wL s a� til1;C din s
C '+
❑lru lion l7-SpNialtyGrunt b Gravel
Non Water.Supirty Well: rJ Bentortite 5lutay J V N,�) .+ ther(explain tinder 7g)
Monitoring. ❑Rtxovery.
injection Well: ;f For each materitjWyv4c4i&Wj' materials used:
❑Aquife>rRecharge ❑Grouridt}alcrltemediatiarr Neat Cem.•471b ,Wtr:3gal. Sand Cem.•lb ,Wtr•gal.
❑AtlniPrr Storage attd Recover' ❑Snliiiily Datder
❑Aquifer Test OSiornmatcr Dttiinage
❑Exp,mi. rental TLchtlulogv ❑Snbsideirce Control 7g Provide a brief description of the Abandonment pmedure:.
Moiltunnal(Closed Loop} bTmcer
tremie grouted.
®Geothenual(Hcadnirl'CoolinQ Mum) LJDdter(cx lain under La
i.Date trell(s}ahandoncdt 5/i/2023
Sn.Weit location:-
Lassonde Pappas Company
Facflitpl0wrwr Mow r.mility IM(Wappli iblcl R•CertiiQcalloit:
485 Brookside Camp Rd. Hendersonville, NC 28792 �s M 5/9/2023
Pltpsicnl Addm%.Ciiy,and Zip !Cts1irj4d well tanim-oofor Well(hero D;11e
Henderson At'v{tp:it�y lhts faint, !henebF certr/y tl:nt the ices!{sJ ors 1trer1J rMandanc•d i11
Caauy' l:lrcel]danlil"tt6thm No.MIN) auanlanre it,id?15.1 A'C"IC 02C,[J00 or 2C_0200.I'Mell Constmrdriri Sfortc&rrds
and tdrnt a crpi ofilris recard has been provided to the ii•ell oti•11er.
Sb,1�ttitude;•tttd tongitude in.degmslminuteske mitts or dixinial degmes:
(irw•ell rct;t,or[t RiUlung 3k inns pml) 9.Site diagram or additional yell details:
You.may.use d e ba&of this N&to provide additional nell site datoils or%sell
35.378088 Tt 82.489455 abandonment details. You tong also attuclt adtlitioualpa�ers if tucess try_
CONSTRUCTION.UE'1'A11.S OF1Vl LLftil BEING.ABANDONED SI TRNIFI •-TAT..TNSTRTTCTiQYR
tffuclr y,rl1 wrslrnciiart rrcnritlsJ Jr usrrllre�il� Fier lrn[trrdilr i1 frctiatr w•rnn•n•ur[r�lppir -
rfelk ONLY:inch 11x sm-ne sirhiml.wrc.funrr. Mai Far-.All Nell.• $ubmil this fumt tsilltin 30 days of completion of well
ibandonmcnt to dic followin,-:
Division of Witter Resourcm,Information Processing Unit;
1617 Mail Scrt ice Center,ILileigh,NC 274994617
6b.Total well depth: 15 (fly .
10b.For Inlecilon Weils:.Ili addition to sending the form to the addross in 10a
6c.ltanitole diameter.2 abotx!_also submit one copy of this forra within 30 days of completion of well
(hij :ibrindounteru to the fullow•iuj:
Divis1011.0f Water Resoureesi.Uuder'grantid inimllou Coitttvl Program
fid,Water level below ground surface: Vt.) 1636 Mail_Scn•icc('enter,Raleigh,KC 27G99-1636
6e.Outer casing length(if known): 5 00 loc.roe h iuivetinn Wells: In addition to sending the fortis to
the address(es) aboge. also submit one copy of this form Mil in 30 days of
completion p1'well abandomnent to the county licatth depattnimil of the county
a hero abaruloncd•
6f.lnmer cusinlltubinp length(if Imaw•n j: (ft.) '
i
6..Screen length(If knoll (ft.)
Fami G%V-30 Noah Caroliro Depatun rn of Endronnicnt and Namral Remixes-Dlt isian of 54'atcr ltaotuctis Revised August 2001