Buncombe_Well Abandonment_20231024

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WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Singleton Environmental, Inc. 7a.For Geoprobe/DPTorClosediLtiop 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
Chris Singleton wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): N/A (gal.)
3328—B FOR WATER SUPPLY WELLS',ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable we.11 construction per7nits(i.e.L/IC,County,State,Variance,etc.)iflmoa7r jl
7d.Amount of disinfectant used:i'
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check:ill that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ` N Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ❑ Sand Cement Grout I ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) S Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge El Groundwater Remediation 7 bags of bentonite.
❑Aquifer Storage and Recovery []Salinity Barrier
[:]Aquifer Test ❑StormwaterDrainage
3 bags of concrete I;
❑Experimental Technology ❑Subsidence Control �.
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer I
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite was poured to a depth of 3 ft and
concrete was poured to the surface.
4.Date well(s)abandoned: 1 0/11/23 tom•�-,a j
5a.Well location: y 2023
Reems Creek Food Mart ;
Facility/Owner Name Facility ID#(if applicable) 8.Certillead •D ;%!T1,,3G
444 Reems Creek Road 10/12/23
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Physical Address,City,and Zip Sign re of Certified Well for or Well Owner Date
Weaverville
By signing this form, I hereby certify that the well(s) Has(were) abandoned in
County uf'j //-1 Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has beef 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:
35.6905 N -82.5327 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
Atlach well construction record(y)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constnrction/abandonment,you can submit one form 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MWS 1,2,3,4,6,7,8,9,10 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 21 9 (ft•) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: N/A (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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6d.Water level below ground surface:Avg 15 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center:Raleigh,NC 27699-1636
N/A 10c.For Water Supply&Iniection 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 county health department of the county where
6E Inner casing/tubing length(if known): N/A (ft,) abandoned.
6g.Screen length Cif known): NIA (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016