Buncombe_Well Abandonment_20240116 (2)

WELL ABANDONMENT RECORD ForlatimlUmON LY-
1.Wen Contractor Inferioron: WELL ABANDONMENT DETAILS'
^G�,�L• f�S 7a.For Geoprebe/DPT or Closed-Loop Geothermal Wens Laving the same
well canft=wNaw(or wen awnwpusaoeIly abandonwS well an bwlw property) well conaftation/delnh,only i GW 30 is needed. indicate TOTAL NUMBER of
wells abandoned:
NC Well Couft idw Cmtifimtkm Nmmba I 76.ApprO:imate volume of wa6Clc iemaimleg in well(s): (gal-)
n C • FOR WATER SUPPLY WELM ONLY:
C �M= lc.Type of didofectant used.•
2.well Construction Permit :
Lht a9appficable xell comaicdonpanrib(La era Cmmy,*We.YarlmraG eta.)0`bwM
7d.Amount of disinfectant used!
3.Well use(cbechwen use):
Water supply well: 7e.sealing materials used(cLeclk all that
❑,Wcultaral ❑MunicipaUPablic 0 Neat Cement Grant II B to chips or.Pellets
C[GooMeonat(Hest ng/Caoliog Supply) ❑Reshlential Water Supply(single) 0 Sand Commit Grout i ❑Dry Clay
❑fndustriaUCammacbd ORaidandal Water Supply(ftrod) •0 Concrete G" t 0 Drill Cutdgp
0M on O Specialty Grout O Gravel
N,oaWater Supply Well: O Beatonite Shiny ❑Otter(explain 7g)
❑14lomtnring a ORecovmty
n wen X For each naterw selected above,provide amount of materials used:
0A pfa St=V and Ra:overy Malrny Basri -
OAqm Test OSbommwata l)naimage
torpeaream Technology .' OSubsideaceControl
7S.Provide a brkf description of the abandonment procedmm
❑Geohe6al(Closed Loop) ❑Tracer
OGeotitC®ai Coo' Reimn Often lain under 7 0
4.Date well(a)abandoned:
Ste: location: i V Zd24
F OwaaNaw Faci tf JD#(iflpplimble) L CArdocadpw Lfi`v ray `�1j
C) •o
aaara�,,cay; z�r s o w «Wall t)wlter _ Dad
i- G '
c't' C.O ter P� By� for^I hereby cao that the wells)was(tvm)abandoned to
Cwmty ftvd No."Q aecordmtee with 15A NCAC 02C,0100 or 2C.0200 Well Conn wilon Standards
and that a copy of this record has been pm Wed to the uvY owner.
5b.Latitude and longitude in degren/mlauta/aeconds or-dedmal degrees:
awin fillet,ape ballad is m9fiieieac) 9.Sin dlageam or aacntlonal well details:
y3 : R, Yea may use 6.back of this page to provide.additianal wall site aebaila or well
abandcmmemt datst& You may also attach additional pages ifnecmsmy. .
rnxrrQrrrernmenmr AM OF WMM BEING ABANDONBD
An=hwIcaxmuc xrewrd(e)jra►aW4 Fors u*Ieirdectlanornar-w9Wm plyxeAs -
ONLYx0 the seen eauar cNoit/aLmrdomna:r;you non au6sUt avu.)— 101.For All Wens:. Submit this-form.within 30 days of completion of well
6a.Wen M ebandammaat to the following:
3 w D�lonofwateri*nre«,Information Unit,
�.Total well ' O 1617 Mail Service(Center,Raldgb,NC 27699-1617
lob.Foe p(eeHon Wens: In addition to sending the form to the address in l0a
6r.Borehole diameter: (ice.) above,also submit one copy of this foam within 30 days of completion of well
absnd®ment to the following: (i
Divialon of water Resources,Underground Injection Control Program,
6d.Water level below,ground saface:- (it.) 163611sall Servloe Center,Raleigh,NC 27699-106 ;
: � ). 3 � ) loc.For water S1mml�Inipftlon wells: In addition to sending the form to the
'address(es)above,also submit ono cbpy of this foam within 30 days of completion
of well abendoom nt-to thc'comriy health department_of the county.where
6L Inkier cssiJiP)tmbimg length(if(mown):
abandoned.
Form GW-30 Nm&Car h=Department of ftmo =W Qarlity-Division ofwater R i xavised Z-z2-zo16

ELL ABAND01 MENT RECQR 1 FalntamslUwONLY:
L WedThactor Info a: .WEI.I.A>l<ANDONMENT DETAILS'
7a.For GeoprebelDPT or Clo4lpop Geothermal wells having the same
waitconb=wNemo(orvmlluwmpasanduyabmdoniogwenonhisAwpropady) wdiconehnetioddeptl:.�ly1GW30isneaded indicabeFOfAL,NiJR4BERof
wells abandoned: f
NC W Coaoaidar 1 ` 7L Approximate volume of water remaining to well(a): (gal.)
1 fir;
�e(.L`7� t."G�.vI7L(� I I ► �*R WATER SUPPLY WELL ONLY: -
cb"PIUNIM 7e.Type of didnfectant used:
2.well Conatrucdm Permit d:
Litt all gppdmble w9 conOud lon pamita(1e.UIC,Carroty,fttA Varlace,eta)b'ir
7d.Amount of disialbetant used,:
3.Well use(theekwell we):
Water Supply Wed: 7e.Sealing materials used(check all that apply)•
OAgdcultmal OMunicipalMablic ❑Neat Cement GWI t , Utentonito Chips or Pellets
-mod(Heatm8/Coolmg Supply) ❑Residentid water Supply(single) O Sand Cement Gsaut ❑Dry Clay.
❑lodushid/Cornmercial ❑Residendsl water Supply(slimed) 'a Concrete Glut O Drill Cuttings
O1rd on O Specialty Ctmut ❑Gravel
�NryJ9water Swp*Wed: , a Eeatonita slurry �. ❑Other(explain wader 7g)
�IViomtoring CRecovery +
Injection wed: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediatian S b
OAquifrr Stoiage sad ReOovery- - `t7Salinhy carrier ;
OAqm
Test OStomtwatarDminage ,
Im'PeorenMTechnology OSubsidence Control 7g.Ptm�We a brief desctlptlon of the abandonment procedure:
OGeothe®d(Closed Loop) ❑Trace' �-�
❑Geothe®d Coo' Retwm OOfher lain undo'7 C'r 1r\ Y1 ► + 'r�r' S (�,y
4,Date wen(s)abandoned:
Se:Well locitlon:` _.... I I A N
:n'
Facitity/Ovv=Na®e..; F-ift W#(if WHable)
pbysi,:al Add«%City} Zip ` sitle okwaed well Cam or wen owner
&k.vi V.6' rv..b'C BY afflft&*tom,I ha*cer*that the weds)was(um)abwdoned to
..• Fneel Idesd8atlonNo.(P1IV) amordince with i5A NCAC o2C:010o or 2C.02oo Well Convducdon s mrdards
and drat a copy of dds record has beenprovided to the webs owner.
5b.Latitude and longitude la degreealminata/seoonds or.dedmd depm,.
(ifwoII acid,om tstflaog3s saffdiest) ;/ 9.site din am or additional wad detals:
O , .) 1
2 .N a t 33 � r You may use the back of this page to provide additiowal well site details or well
R' abandonment dote7s Yon may ciao attach addRional pages if necessary.
CONSTRUCTIOli?D)�TAIGG�OF WELL
Aaaeli»ellcon*tnrdloiimmd(a)�a►nRable.Poreaelf#plebiJectlonornon-xisterauppfy:ttsAt
ONLYwiti Meson 6=&uidoWabandomnentym!asrrx&bN&omefaae. - - 10a.For All Welts: Submit this-form within 30 days-of completion of.wen
6a.Wed IDflr L abandonment to the following:
BM&n of Water Rewurce 6Information Proms Unit,
lib:Total well depth: • (ii:) 1617 Mall Service(Center,Raleigh-NC 276"-1617
10b.Far Inledlon Weds: Ice additdan to sending the fora to the address in 10a
lie.Bor steels diameter: above,dso submit one copy of this f mi within 30 days of completion of well
abandonment to the following: I
lid:Winer level tidow grcoand sarfitce: ( ,) Division of Water Resota�'Underground Injection Control Prognink
-1636 Mad Serdee Centre,Raldgb,NC 27699.1636
lOc.For Weber Suunly A Injudeti Welts: Inaddition to sending the form to the
C ater easing leng&(if lmmm): _/R.). (es)ate,also submit eras co y-of this fomt within 30 days of completion
of well abaadonma to_the county health department of the county where
K Innetcadog/tubing ienSth(itlmown): " � (R,) abandoned'
6g.Screen left t Of ling"). 1 (it.) :
Form GW-30 NmNt CEWina Deprlmmd of BaWmammtd Quality-Division ofwatuResomc Revised 2 22-2016