Buncombe_Well Abandonment_20230724

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contra for Information: WELL ABANDONMENT DETAILS
O Moo 7a.For GeoprobelDPT 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-30 is needed. Indicate TOTAL NUMBER of
qi V 1 wells abandoned:
NC W 11 Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
FV "� ( FOR WATER SUPPLY WELLS ONLY:
Company Name t
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable a ell construction permits(ie.UDC County,State,Variance,etc.)iflarotvn
7d.Amount of disinfectant used: C.�.
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/Cooag Supply) rdential Water Supply(single) ❑,�Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) �ncrete Grout ❑Drill Cuttings
-❑Irrigation_— — — ❑.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 ❑GroundwaterRemediation Yd
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description ot'the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: �oC l hC
52.Well location: 1
JUL 2J 4. 2023
Facility/Owner Name Facility tD#(ifapplicable) 8.Certifica
Real Address,City,and Zip Signature e W ll Contractor or Well Owner Date
WI Comb q7e��l s 47000�n By signing this form,1 hereby certify thal the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 75,4 NCAC 02C.0100 or 2C.0200 Well Consttilction 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details-
,W19�b i5 You may use the back of this page to provide additional well site details or well
o' �) l r��' I N �C�-1 t �l W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailoble. For multiple hyection at-non-watersupplywells
ONLY with the same construction/abaudomnent,you can submit one fontt.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• abandonment to the following:
l Division of Water Resources,Information Processing Unit,
6b.Total well depth / (ft.) 1617 Mail Service Center,Raleigh,NC 276994617
I IOb.For iniection Wells: in addition to sending the form to the address in l On
6c.Borehole diameter: (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
1
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.) IOc.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
6E Inner casing/tubing length(if known). (ft.) abandoned_
i
6g.Screen length(if known): I'1 (ft.)
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016