Buncombe_Well Abandonment_20240311

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WELL ABANDONMENT RECORD For Internal Usdm1LY;
This form rah be used for sinete or muliipte swells
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I.Welt Contractor Information: WELL ABANDONMENT DETAILS ! -
Robert Miller . 7it.Number ofArdis being ahandauchi!5
WeneorlrnelarNona!(orct&IC\YlaYpeuonally.nluntanlaeaeitantaillterprapcny) For ruidnplc. t+fertlar .or mu-water I supply wells ONLY with ate amne
r Mtructionvbandoi!eL'ot,lY/N Car submit i aefarrt.
2675-A
NC Well CamrtporCcnifirailoti Nnrrbcr - 71r.Appmximatc volume of* t �rneinaining in w ell(s): , . (itL)
SAEDACCO FOR WATER SUPPLY WELLS ONLY: •
Co:pan Namc 7e.Type of disinfectant used: i I
1♦Vell Cansttvction Permit 4:, , WI0100704 j
List oil spplkkr+ble nrellpertrits(i. Cos ,Star,Variative.brjertian„ek i tJdnu!vn it..luionnt of dliinFectaint'ltsitl:
3.Well use(dieektt•ell use): 1 . . . . . .
Water Supply Well: - 7e.Sealing materials-used(cheer;all that apply):
E3Agricoltttcat" titrlcinicipalfPubl[o to Nett Cement Grout , F DI 13cntonite Chips of Poppets
°Geothermal(Heating/'Cooling Supply) °Residential Water Supply(single) -El Sancl'Centent Gmut ' ! El Dry Clay
❑huhisttial(Comntcrcial °Residential Watcr•Supply-(stared). G ConcteteGrout" • i 1]Drill Cuttings
Ohrigation l7 Specialty Gruut -i7 Gravel
Ron-Water Supply Well: El Bentonite Shiny 1 °Other(explain under 7g)
OMarittoruig. . . • °Recovery i
Injection Well: L - • • 7f.For each Material selected above,provide amount of materials used:
o Aquifer Recharge DGruttitdnnter Remedintinn , I
°Aquifer Storage and Recovery ,°Salinity Barrier •
°Aquifer Test OSlomnxaterDrairiage
Bentonite.:251b ,Wtr:gal.
•
OEpperintental Technology °Subsidence Cottml 7g.provide a bricfdcscription of the abandonment procedure:
°Geotitennal(Closed Loop) °Tracer
Pulled,tooling-and abandoned boreholes w/ granular
°Geothermal(Heaunn/Cooling Return) C]Other(explain under 7g)
•bentonite. I
4.Datesscll(s).abandoncd: 2/28/24 _ 4;' r '�` '
5a.•Welllocation: ; 1
M,11n 70Z4
Zboyovski Property .
.8.Calla-Muni;
Facility/OwnerNnoc FacilnylDM(ifupplicable) lniZ;;;Y3b:i: 1 ?r-.
196 Smokey Park Hwy. Asheville, NC 28806 ,/j�J" j Qi�r"3' a 2/28/2024
Phi•sleat Address.City.and Zip' Sierrah:f.0:'•"re.'.s::'*g::ti'%;;!,St, 'S4:v rx:r . .Dale
Buncombe . - Br signing Mix lanai 1 hereby certify that the waifs)Hex Owe)abandoned in
County Psi 1 ldcritifie it!ai Na.(PIN raccvrrlrntce with l i;1 NCAC 02C.Ol(l9 or 2C.0200 1Ve41`Co tstrttclion Standards
' 'and that a copy ofthis record has been provided(o Jie well owner.
SU;I,ltilttdc and longitude in de grceshntirtutesdseconds or dormer tl1degreesi i, '
(ifnclt fold,one btflung is snrtllcier>t) 9.Site diagram or additional well denitls:
You tuay use the back of this"page to:provide additional isiell site details or well
N W .atbandonmentdetails. You may also attach additional pages if necessary_ •
CONSTRliION DETAii S ON WE BEING ABANDONED ;SUBMITTAL ;
f'P ,
.afar nrctl,romirnotiort tear-dfs)If ovth1abdd. Fur naiTpie infra-flare-or rw,j.lsrrlu•apply - - i
uxllsONLY u-lJi tlruminige rnstnirtwre4armrrloyrural,iron or ntbmlr one firm. Ina, For All Wells: Submit this foist avithin 30 days of completion of ell
6a.Well ID :B-1 - B-5 abaandoiuucnt to the following: . 1 I -
•
Division of Water Resaur ,l ees Information-Pracessing Unit,
(D.) -,1617 Mail Service Cetirce Ralet li NC 276r99-1617
6b..Total well depth: 33 ' •
10b.Fnr.Tnleclien Wells: In addition to;sending the form to the address to Ella
fc.Barcholc diantetcr:l•5 (in.) above,also.submit one copy of this fount within 30 days of completion of bell
'abandormteut to the following: i I
1.
fid.Water level below ground surface: (ftJ Division of Water RControl-Program.erground injection Control-Program.
1636 Mail Service Center,Raleigh,NC 27699-1636
Ge Outer easing dlmrrsvn); • (ft) 18c For Water Sootily.0 infection Wells: In addition to.sending the form to
g length( Hie addresses) above, also submit one copy of-this foot within 30 days of
• cotnptctiou-of well abandonment to the'.county health departntcrd of the eontr(y
6f.Inner easing/tubing length if Imown° where abandoned. 4
6g.Screen length(if known): (ft.)
Fans GW-3o Non Carotins Demo:mi i ofEnvironment nib Niuurat Renounces—Division of Rimer lteso scaei ! Revised August 2013

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WELL ABANDONMENT RECORD 'For!ro m l:Use ONLY; 'I .
This brim can be used for-single or multiple wells"
1.Well•Contractor inl'orgiation; • WILL ABANDONMENT DETAILS'
Robert Miller . . 7a.Number rif wells being ahandraneldJ '
Welt Cot rac/orNanie or fate to r rsonam ablintanino„ell anbkikr r cn For multiple. li fcetlwr or rota-:rtrtcf !supply. wells ONLY uOh the .awre
( 1> y' P°p•-51 canter terinn•'abaar, sent,iva carsntwuurfform,
2675-A
I"
71).Approximate volume of watt.remaining in ivell(s): .)(Rat
NC WellConlracierCenlfrcattouNmiter .
.
SAEDACCO FOR WATER.SUPPLY WELLS ONLY:
Company Name " 7e.Type of disinfectant used: I
2.Well Construction Pcrtitlt if:, , W10100704 ,
Lis!01 applleafrle well perarits fie.Coat*Stara,Yur&emit lufeetion,-olc:-1 IIfbawl - lit.Amount of dislnfect:nit us 41:
•
3.Well use(cheek well use):
Water Supply Well: 7c.Sealing mutetials_used(cheek all that apply);
lJAgrfenititilt[ l7Mtinicipal/Public• l 1 Ncat Ccrucnt.Grout • ! via Bentonite Chips or Pellets
17Gcotkcnnal(Hcating/Cnoling Supply) Dltesidentihl Water-Supply(single) ❑Sand Cement Gmut I ❑Thy Clay
❑htdristrial/Commercial- ❑Residential 1Vntcr Supply-(sliaued) ❑Concrete Grout ❑Drill Culiinps
•
❑iIdeation ❑Specialty Grout 1 O Gravel
Non-Water Supply Weil; - ❑HentouiteSluny° . : ❑Other(explain under 7g)
❑Monitoring ORecovery , . • 1
Injection Well: - • • • 7f.For each material selected above.provide amount of.Materials used:
❑AquiferRecliarge . EIGniuinitt;iler•Rentedfaaion
DAquifer Storage and Recovery ❑Salinity Barrier
❑Agurfer Test ❑SlonmeaterDrahiage
Bentonite.:251b ,Wtr:gal. I
❑Evpa riuleWul Tochuotagv- OSubsidetxe Control •7g.Provide a brief-description Of thelabandnument procedure: •
OGeothermat(Closed Loop) ❑Tracer 1
Pulled tooling and abandoned boreholes w/ granular
®Geothermal(Heating/Cooling Return) Maier(explainunder 7g1
bentonite. •y I'4{_`E .M-•"�3�0�
-
•4.Datewcll(s).abandoncd:2/28/24 I: Li
5a.Well location:
Zboyovski Property tiapi-l17?,,om;Pr^,c.up ryas!f.1rrsi
8.Certification; f D '
tev ¢. .4
Facility/Owner Rams Fxfttty MM.Orappliwbic) -3
146 Smokey. Park Hwy. Asheville, NC 28806 ,/�� II 2/28/2024
• •Physical Address.City,and Zip Shelf:(c of:.,r %t:' ;ii��; (.w... d:+„+a wr , Oslo
1
Buncombe • 11y signing!Iris farm, 1 hereby cerlijy'that the wed(s)was(were)abandoned in
County Parcel tdcrillfiaidtru No.(P111j accordance with LTA.h:CAC 02C,010.0.or 2C.0200 lt7e11 Con:rrrticliun Standards
'and aural a copyoftlrisrecord has beearprwidedtothefeel/owner: '
SIe.J atitude and longitude In ttegr'ces/minutes/scconds or-decimal-degrees: ' • I, 1
bait/long
(it%veil rsld,one tg srticier:i) 9.Site diagram or ndditlouat well details: •
You tuay use the:back of tliispage to provide additional well site details or well
N - ' - W abandoimieid details..You may also attach additional'pages if ilecessoty.
CONSTRIt(TION DETAILS OF WELLS)BEING A13ANDt)NED eUB8i11TAL INSTRUCTIONS
Math feel!c,rmrractnua mcurd(s)if available. liar multiple illectian'ar rdna•w aiir supply '
wells ONLY with the same:rointraekwriabutr;hauraacmt.)ea can rebuilt oneAri. 10a. Far All Wells; Submit this folio'Within 30 days of"completion of well
Ga.WeU ID#sC-1 - C-7 abandontacnt to the following:
DlViski n of Water Resoureis l infornntlon"Processing ilnit,
6b.Total well depth: 33 (ft.) 1617 Alail Service Centcri1Raleigli,NC 27699-1617
•
lOb.For inleelton Welli: In addition to sending the form to the address in lOa
fee.Borehole diacuctet 1.5 (iu.) •
'above,also-Submit-one Copy of this fonli within 30 days of"completion'of Well
aW'auionitient to the fallowing: I'
• I
6d.lVaterlevdbc[ow ground surface: (ft.) -Division of Water Resources,Underground Lijection Control Program,
1636 Mail Service Cents•,i Icigh,NC 27699-1636
6e.Outer casing lcn,^,W(if[mown): (ttj lOc.'For Waiter•Sunnly•&infection Wells: In addition•tosending the form to
the addresses) above."also submit Ode'copy of this form within 30 days of •
completion-of yell abandonment to the county health department of the county
6f.Inner easing/tubing length(if!mown); (ft.)
where abandoned. -
6g.Screen length(If known): - (ft.)
Faml G1W.,M North Carotin Dcpsnnrcm of Ent'lronoicnt and Naluml Resources-I h'islori of WatcrRcsoul'5 I Revised August 2013
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WELL ABAND.ONMEN.T RECORD For lntaniatUscONLY:
This form can be used for single of nttiltipte wells
1.Well Contractor information: WELL ABANDONMENT91RTAiL.s
Robert Miller 7a.Number of wells being abanduncIdi 5
WgliCoulradorN3nte(oraillowr.persntraltyaban;[onluattiell.onlusierpiolioly) Fir rrochiple injection. or' r.on-vuuee'1svpty wells ONLY will, ilk some
aorutructiori itorrrfnutsient,po can submit 04rnr,
2675—A •
NC Wcl1 Conlrndorter111iratioi hborber
711.Approximate snlunte of water•remaining in w•cll(s): . (gal)
• SAEDACCO FOR WATFR SUPPLY�I ELL S ONLY:
Company Name I'
7e.Typetrfelisiofeetont userl: •. i 1 .
•2:Well Construction Permit#:, , W10100704 • I -.
U:e1 rill opphivbte 1411parurise(i.e.CvririN,Stet,Yariurree.Lrjectiart.rtril illarnwrt Id Ainount of dlstnfcct int used:
3.•Wdl use(chedcwell use): - is , - •
Water Stipp!).Well: . 7c.Sealing materialsused(chat~all tii at apply):
•
DAgricuttttrat DMtinieipaUPublte: 0 Neat Cement.Grout I ' W Benionitc`Chips orPcilets
RGeothcrnnal(HcatinglCooling Supply)' Ottcsideminl Water Supply(single) O St;tdi Eii i!rtt Gtnut - j' i ❑Dry Clay
❑hidusttial/Cotnntcrcial • ORcsidenti,'tl Water Supply(shared) ' El Conetelt,Gtout 1 .CI Drill Cuttings
_9 Inigation - . C Specialty Grout • I, ❑Gravel .
Non Water Supply Welt: O Bentonite Slurry
OMatiitorine . . lRecovety' � I. O Other{explain under 7g)
. Injection Well: - : ." 7f,For each material selected above,ji•rov ide amount materials tined:
• OAquiferRecltargci ®Gruwuiw-ier.Rcntediatimn I .
CiAqutffr Storage and Recovery • OSalinityy Barrier
'OAquifer:Test OS[animater Drain* Bentonite.:251b ,Wtr:gal. i ,
DExperimtetilal Technology •0Subsidence Connml I'
7g.Provide a briefdL.scriptian Of the uUiuialnnrncat prnci•+lum: •
OGeothentnl Posed Loop) OTracer II
Pulled.tooling and abandoned boreholes iv/ granular
.0Geothenual(11eatinai'CoolingReium) ©Otherlexplain under 7g) . . .
bentonite. • 1
4.Bate we s).abandoneti:2/28/24 S- '1-.:'
.. c v/c'`
5a WcU luentlon: . . . . I'.MA K 1 2024 .
• Zboyovski Property - , ,` i
Facility/Owner FxilityIDe(irappliwblc) 8:Cerli[Ictilioil: Intc.i Tl ;en ?,r• Ny
VYVC 3
146 §mokey Park.Hwy. Asheville, NC 28806 • 2/28/2024
Physical Address.City.mid Zip Sigh .r>k•tS S.:'"F;bt y,,:e;,!at..• 5 +s•ti:r Dame
Buncombe 11y.signing this 1 herby cer►ify that the well(s)weer()rape)abandoned in
Couuty Parcel ldcrilit"t,ca11int No.(PIN) ttirvrrlaina with15A NCACO2C,01p'O:or?C.0?00117e11;CunstuUiafiStinrktids
and Oast.a ivy of this record hasbeiar propided to tare well owner.
5b.Latihtdc and longitude in debm es/minutes/seconds Or deeinuutl degreees.
(Ifsi•clt nerd,one Uttllong is sarlriricrz) 9..Site diagram or additional well derails:_ •
You may''t�e the back of h as page to`pr to ide additional twit site details or well
N . W .abandaimtetudetails..You may'II1St1 altacbtadditiomal pages if ntecessamY.
CONSTRHHCrION Dls'r,'11LS O VF LL(S)BEING AB;1NfONrD d UBMiTFAT.INSTRUCTIONS
:reruns e(r/lrorrruncttwi rrcurret l if avoNruta. .Far imrlriple i lierrioreur boar wmr stippiy ' I
usllr ONLY Will tik mile:t ursmletlordrabarr t inilit.ier eon whist w,ehi* Loa; For All Wells: Submit.this fomi within 30 days at'completion of well
' 6i,Well B}#:D-1 - D-5 abandonment to the fallowing:
,, I
•
Dlcisirin of Water Resouret.n,Info ntioo Processing Unit,
6b.Total well depth: 33 (1}) •
1617 Mail Scriice Center; rrn
Raleigh,NC 2769'9-1617
10b.rnrl'nleclfon Wells: In addition to I udii g the fonn to the adthuss In 10a
6c.Borehole diameter:1•5 _(in.) above.also submit one Copy of this form;witlaii 30 days of completion Of*yell
ubiiti omnent Indic following: I.
• ',
Division of Water Rcsoutres;Undergrround injection COMM'Prtgratu,
id.Water level.below"ground surf see: (fr.) 1636 Visit Service Ccnrerl3talcigh,l\C 27699-1636
toe Fnr Water•Stmnly&infection Wells: In addition to.sending the form to
be.Outer caring length(if lanwn): • (ft.) tile,address(es)above. also submit onel copy'of this,form Within 30'days of
completion-of well abansiaitmcnt to the otnirtty health department of the county
6f.Inner east ng/tubing length(If[mown); (ft)
where abandoned, I
t
6g.Screen length(if known): . . (ft.) I'
i
•
Fomi GW-30. Noah Carolina Dcputmcnt ofEntiroomcm awl Naltrtst Rcsouires—DI Islon of Water Rcsotuces Rcsiscd Aqua 2013

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WELL ABANDONMENT RECORD .
For Inland Usd ONLY;
•
This form can be used for single or multipte wells.
' .1. •
J.Wett Contractor Information:. WELL ABANDONMENT-DETAILS
I 1
. Robert Miller . . 711.Number of with being abanditned: -
Well eouiradarNanic(or nellOnna personally abancioning nell an Ifisdir puipcny) For traff01710- tqlgtifor a" 12°U'll'all,e111 ._SUPPb. W41115 ONLY 'with Ilk scale
eonstruatealabantlohtuorit„itut ctur subuticovjeprm,
2675-A
711.Approkimate volume of riatt.T remaining in*alibi): . . (g,tiL) •
NC Vell Ceniractar tett Ilicitiimi Nantes- 1-. .
• • . •
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
.
ommany Name' . ' 7e.Type Of disinfutant used:
2.Well Construction Pernik fir, ,.MO100704 ' . . . .
LaridlivpllioPle lid!pqmits 0.4...evaiuy,.4tohl,Variance.iiipaiiim,,eli ifkrungio Id.AmoLitit of dishit.e.cont ,d,:,
3.,Well use(cheek we.11 use):
.. .
. . . ,•.. . . . • • - .
Water Supply Well ' • . .7e.Sealing matcrintsuseti(check:2110in apply): ,
• OAgricultutai OMunicipal/Public, 0 Neat Ccnicnt grout 1. IX BeMonitc Chips or Pellet's. •
,.. ., .
•
°Geothermal(11ealing/Caoling Supply) 011esidenthil Water Supply(single) , 0:silnd-cellteill GrolLII ' 1. El Dry Clay
0 Inthisni.11/Cannitercial ' EIRcidential WaterSupply(shared) CI-CauereteiGroul ' ,- Cl Drill Cuttings
Oktigation ' - _. O Specially Grout 1 .0 Gravel , , •
..._____. -- .
Non-Water Supply Welk - 1:1 Bentonite Shiny • ' Cl Other(explain under 7g)
• OMmillaring-. . . , OFtecovery
injection Well: ' - . 7f.Foreath Material Riveted above,preside antount attittiterials tnetl:
1 I
ElAquilrey Recharge . - 112Gniinuttrater Reniediation 1' I .
OAnnifer Storage and Recovery .OSalinity Battier
•
. • . Bentonite.:251b ,i4tr:gel.
• OAllitifer Test • OSMninvater Drainage .1:
. - Otxpitinterital Technology. PSubsidette bontml. , 9g,.Pros-idea brief description Of thC,abantlnitmcnt procedunn . .
rigeootennat(Closed Leap) . OTracer .
Pulled tooling and abandoned boreholus,w/ granular.
. .C1Geothernial(Heating/Cooling Return) • 00ther(explain under 7n) .
• ' I
L r\4''' .-
bentonite. . ! L. is C
•
., . • . •
4.Date welt(s).abandoned:2/28/24 ' '! I ' MAR 1 1 2024, •
. . .
•
Sa,'WCII Inearion: •
.
• Zboyovski Property • . . • l' I DWibi.'13.',3(...3..1"V'JO tlfiCer S.c ati0H:
Faeltity/ChvnoNluilc Facility Inn Orapplicable) . 0 .
- 146 SmOkey Park Hwy. Asheville, NO 28806
•-4L7016‘. -.V..,417. - ''. l' . -2/28/2024
• Physical:Address,City.-and Zip- Signanic tir',;ze.'.,;:,:f.1:7 eq.?!‹..-;=•:1C:.'tt ,,.,..-,Ator
. . . . Bate
It I
Buncombe _ . • • , , By fignIng'flits fin7n;1hereby certffr•tbOt the Ivell(s)N'17.37 OM*abandoned in
Parcel peniiii6tion No.(PIN) accordance iville"15A:WAG'02C,.0100i pi-2 e.0200 Well:Constiwction Standards
and dui'a copy pith&record lea&been#rOvidedto titan ihwer,
Sit,Latitude and longitude in*give' stminuteesciands or decimal degrees: I 1 •
. I
(Ifwelt(eld.ow Lailong is sofficlein) 9.Site diagram or additional well details:
W. You ma);use the,back,of tins page to'pros additional well site details or well
• N - - ,ahandoinuentditails.,You may also attach initlitional pages if necessaty.
. . • 1 I ,
.CON'STRilLTION DETAILS OP WELLIS)REIN('ABANDONED' : SUBMITTAL INSTRUCTIONS !: I
Attack,1141 coasirudidit rutirtlis)If uktilable. •for multiple iMectitui or I-jemmy:op.supply
wells ONLY WO thesom.aritstro.ctionlakutubitkierit.put MU 1:16*.0.1Wii.IfIl. laa.,For All,Wells: Submit-this faint cithin 30 days of completion of well
•6a,Well ifithE-1 - E-4. . . abandonment 19 die following: . • ; 1'
l' I - •
Dfyisitin af Water RonuretN,,Information,Prociing Unit,
• 6b.To talivell depth:
1617 Mail Service tenter,Raleigh,NC 276994617 •
3 "• 014 , i • •
. ,. • - . 10b.For infection Wells: -ht addition 10'sending the foma to the address hi 10a
• .
above.also submit one Copy of this Canni:withiii 30 days of Comptetion'of well
6c.Borehole diameter:1.5 tin.) abandonment tothe following;
: . .
Division of Water Resouriesillodpiround Injection Colonl;Program,6d.Witter level below ground .round surface: (ft-) 1636 Mail Service Center.11alcigb,NC 27699-1636 _ •
.
• • 10e.For W-tter Sminlv A Titfeetimi Wells: In addition-to sending the form to
6c.Outer easing!nob(if larown): (R4 ,the address(es) above. also submit budCopy of this.Ibm:within 30-days of
completion-of well abandonment to thcicaintty health depattmetti of the county
• where abandoned.
GE Inner easing/0)in length Of lama* (ft.) 11
. .
6g,Screen length(if laiown): (ft.)
t,
I I
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Fon GW-30 North Carolina Depoquont a linvirollinent and Nktural Resopires-Ohidon of Water Rcsoitrccs I: gevicil August 2013
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WELL ABANDONMENT RECORD For Internal Use ONLY: II
ThIs form can be used for single or multiple wells
I .
J.Well Contractor Information:- WELL ABANDONMENT DETAILS
• I
Robert Miller . ' . 7a.Number Of ndls being abandanedi
WelleourraMor Nook(or nett einem-p:.,rsannly atraMioning well On Midler proticrty) For midnple Injection or non-wentte‘i.supj# wells. ONLY 'with the..i0111t.,
C00417T(Cflkleitlandailelh??0,VON cote embnitriutefirror.
2675-A , ' - I 'I
7!).Approihnote yolome of watir reniaining•inivell(s): • . : (gaL)
NC.Well ContractorGailtimaion Nutiber . ,
FOR WATUR. UPPLYWELES.OY:•
SAEDACCO . . 1
Company Name • Te.Type of disinfeetoni urea: . •' .1 . . . .
: 1 .
I Well Construction Permit 8:, , W10100704 • •
a1 all oppllivirk well permiti ji.e...Catruy,-4.ye,Portotrex..hrjectiefd)'flamer! 7d,AntoOM of disinfect:hi-used: 1. '
. 3.Well we(clicelr well use): • • . .
• .'. '! i ' . . • .
. .
Water Supply Well: . . 7e.Sealing miterialS.uscii(Cheek.ill that'apply);
1±144.trieulttirat - bMitnitipal/Pol?lie, " Cl Neat Centent.(3rout l' , 121.13emonitc Claps or Pellets
1 .
• bOcotircrmal(Hcatin*Cooling*ply) • ottFsidennut Water supply(single) • El 5P'ild.fen104 Grant i 1 13.DRY Clay
El Indastrial/Commercial • imietidentini-Water Supplyishated) .El.ConOute:Glaul 1. - -1:1 Drill-patinas
11 , • •
Clinigatien . . . . . - . . . El SpecialtyGroul ' ,, El Gravel
- 1•[ . .
Non-Water Supply Well: '' .II 13entonite Shiny ' : 1 0 Other(explain under 7g)
. i, •
• OMmiitorine ' • ORecovery
• . Injection wcii: - - -- • • 7E Forirach material seletted above,*ride amount Of.Materials rfsed: . •
DAquiferReebarge, . BlOniuirdwater Itentediation • :'.'1 -
•
fiAquifer Storage at411 RedoVery .1:1Salinity Barrier .. • 1 1; .
Bentonite.:251b ,Wtr:gal.
• IDAntrifer Test ' CISMnantoterDmiriage• IntverintentalTechnotoev cjSubsidetre bintrul
Tg.Provide-a'yid d6crIption of the abangonnient prnettinre:
OGeothermal(Closed Loop) - L1Tracer: . • i -
Pulled tooling and abandoned,boreholes w/ granular
DGeotheimal(Heating/Cooling Return) • 1:101ficr(explain:under 7u) L)
• bentonite.
I
. il
. .• .
. 1 i [-•-•1/4..,LZ i 1"..
4.Date well(s).srbandoncdt 2/28/24 '. ti. .
inf.(..7,7•11•P',..1HrFT1, ,,-,.-:,--...*.i.ri,g o
• .
5a.Well locailon: M A R I 1 4202
' . . . •- . •
Zboyovski.Property - , • - . .
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Ficilityithmer Natter Facility IDtt trapplicablet 5.Certilkatio : th
, 1 utto Cti 30G .
14 6.Smokey Park Buy; Asheville, NC 28806 . ...k.'7.0,L.C. „.. 4.1.1-- • . : i; 1 2/28/2024 . . .
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. - PhySical Address.City.and Zip Sigrolit4 Orr,',-.. ..1:1:771.-.':..'nvii4eP..1-.11-N.7"—e...v.V(ivrqr Dale
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Buncoiribe . • By signing MO ppm; 1 hereby certiA.that the irell(s)wax(were)abandoned in
Com* , Parcel litentif=ninit No.(PIN) aoectrlance with 15.1.2,0r4C 02e,,olo9:0,12C 11200 Wellrolistiliction Staeckarils
• • and that a copy oft/us record has.'been provided to the well Owner.
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51).1.atitu de and longitude hi degreestroduutestscennds'or decimal"dcgrces: IN -
(lriell rield,one 1:0/1011.,a is mightier:I)- 9.She diagram or additional welf deltatLi:
• . . You.tut the.back af this page to proiide,additional melt site details or Well
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• • W. .abatidoinowdetalts.:You may alio attaeltidditional pages if riecessaty. •
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CONSTRUCTION DETAILS ini%VELL(§i RE1NG ABANDONED . RURMITTAt.INSTRUCTIONS 1
moth tiO.Fornenearm recortlo tilloble. -For multiple injection'ar tia.inrwatIr eamily - l',- 1 .
ireAra ONLY with the sew consouctionith andomnern,?AI CVO sub*pre form. 10m-Far All-Wells: Submit•this Conti Within 30 days:of cotnpletion•of well
60.Well 1D#:F-1 - r-4
• 'abandonment to the following: '• •
BOision of Water Resourcti4nformiltion-Frocesiing Unit,
5 . •
6b.Total well depth: - : (ft.) . '1617 Mail Service Caner;Raleigh,NC 27699-1.617 .
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33
10h.For-In leellott Wills:•In addition to sending the fain to the oddreSS In 10a •
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• above.also submit one copy of this form within 30 days of completion Of well
6c.Borehole diameter:1,5 . (in.) • abandonment Itithe following: l' 1 ' •
• • Division of Water Resouremilluderground Injection Commit Program,Water tivel.bclow g .round surface: - (ft.) 1636 Mail Sex-sire Carler4talcigh,NC 27699-1636
1 '1 10c.For AliFitemSmiolv'ier in leetio0 Welli: In addition-to sending the form to
6e.Outer casing length(if known) (ft) ;the address(es)ginKe. also submit one copy of ibis form within 30 days of
compietioti-of well abandonment to the cdiutty health department of the county
where abandoned. 1 11
(If.Inner casing/tubing length(If[mown): (ft.)
6g.Screen length(if known): (ft.) ,1
1
Farm GW.,30 Noah Carolina DeFqritirri1 of Environment am]Natural Resources—Division of Water Resourci.1 , Rev i'ed August 2013
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WELL ABANDONMYLEN.T RECORD rat lnlciiutl Use ONLY; .I
This font can be used for single or muliipte wells. .
1,Well Contractor lnthrntation: - WELL ABANDONMENT DETAILS I . •
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Robert Miller 7a.Number arm-ells-being abnndan Id 14
Welt CodmetorName or%tilltiwia�r tsortall.altamkmtlneaellenitisllter r Fur multiple tuleettwr or fon-liYlfer 1I supply wells' ONLY teltb ilk swne
( Ik s p�nS) , I.
cmtsfrrtcnrxt.eubmdlonmenf,)vN eau mahitlr oneforu:
2675-A Li
TIC Wci1 t bniraaorCcdificaifon Miter71t.Approzimxte volume of:tatty.r nl ining in%tiell(s): •. • (jar.)
SAEDACCO - FOR WATER$UPPLY WELLS ONLY: •
Colosimo'Name 7e.Type of disinfectant tined: . 1 - .
2:WeliConstructiotr Pernik a:, , WI0100709 •
Ilse ltfl ytpllruLle wellpmaiiis fie.County,Stele,Yurium e.hfrcriotr.rrcl If bogy 7d.Amount of disinfectant used ! i .
3.Well uSe(eheelcwell use): .
• Water Supply Well: le.Sealing mtitetiais:used(dtcct:all that nipple): • •
IDAgrieultiint . • - EIMtinteipal/Publie, ❑Neat CcnientGrout• I CZ Rcntonitc Chips or Pellets
lJGcotlicnnal(Heating/Cooling Stipple) •iJttcsi*ntial Water Supply(single) 17 Sat dfientrttI Grout ❑Diy Ctav
'pbtdustriallCommcteial ORcsidential Water Supply(shared). 0 Cpncmte Grout 17 Drill Cuuint s
' Mitigation d SpedaltyGrout - 1 I7 Gruel
-Rog-Water Supply Well:- ❑Bentonite Shirty . ❑Other(explain under 7g).
t7Motiilorhtg i7Recoectp ,'
injection Wcll; - 7f,for-each material selected above,provide amount of materials used:
❑AgniferRecltarge DOrein:d :ter.RentPdisrtinn
DAquifer Storage attd-Reco�•ety .bSaliitity Battier , 1 •
CAquifer Test' . DStortmmterDrainage • •
Bentonite.:251b ,Wtr:gal. I.
. UEgtetieneWalTewchnology ❑Subsides.eControl.
7g.Pros'idc a brief dcscriptitin of thc:ishanrinntncnt rroeOdun:
❑Geothenual(Ctoscd Loop) OTracer j '
Pulled.tooling and abandoned-boreholes w/ granular
OGeothermal(HeatnnglCootingRetum) COther(explaia under,7g) • . -
bentonite.
4.Date ett(s).gbandtinc<!:2 2a 2a h: I'4 i}`(k_, r 1Vf""• ,
Su.-W'e0 location: - F
Zboyovski-Property 1 �9��r-i 3 •[�C4
.ii.Certification:
Facility/Owner lime Facility lire,(Fappti able) IrliLria-ta i n ?,•-..` - . t
196.Smokey. Park.Hwy. Asheville, NC 28806• • i L'l/CI;.J3 /2P/7029
Physical'Address.City.and Zip' 5% pt1.%•c' r', ,'t ti,r..ti..•.c, :v,-t cry r Pale
• 1,
Buncombe - By sighing this Enron;1 hereby certify.rki the ire14s)time(wtere)abmuiated-in
. Camay Ptucel liketiliccitlaallo.(PINN) irccxrrtdmrte irtllt 15A ACAC 02C..0100.0rl2C.0200 Well Caris'linction Star:dard
-add Mai a copy earls-record has beenprovidedlolhewellouiler; •
cb,,l:atitudcAnd longitudein degrees!minuteslsccondsordcchuol'degrees: - i;
(IfnC1Irietd,ate at/lonaisatllctera) 9.Site diagranroradditionalweltdetails:.
You tuap.use the back of this.page to pit:Side additional Sven site details.or sell
. • •N - - W- •abaudottntetu-detalls..You may also attach additional pages if ttecfssaty
it
C(INSTRIIC'I'ION DETAILS OF WELL(B)BEING ABANDONED SUBMiTTAi.iNSTRUCT1ONS ' I
:roach bell vew:idlen nwrdfs)if=gable. -For multiple injection'err nen•irutrr supply -
welleONLYulUhdm!.semi.ewubrsctSoMubeirthuteleau,iauattrsrrbmii oreftnic 10a.For All Wells: Submit-this fomi Within 30 days of Completion of well '
• • - abandonment to•the fallowing:
6n.Well ID#:G-1 - G-9.
Division of Water Resourea,Information Processing Unit,
33 .1617 Blot Service Cctitcri,liLdeil ly NC 27699-1417
6b.Total:wclldepth: • (ft.)'. -
- - 10b.For.inIeeflon Wells:-in addition to aetding the font to the address hi Lou
6c.Borehole dLtmctet:l•5 (in.) above.also subunit one copy of this font)Within 30 days or completion of well
abandonment hi the following: _ I' -
• fid.Water lcrel boom ground surface: (ft,) -Dhisiott of Water Resources,Underground Iiijection Control Prdgram, •
1636 Mail Service Center,Raleigh;NC 27699 1636
Ge.(hiker.eosin I of! ( .) loc.ear,Willer-Stmnh•'&Infection Wcllc: In addition to.sending the fonn to
gcag t( rotten):. .the address(es)aboge. also submit one r.opy of this fonts within 30 days of
completion-of well abnndoiunent to the county health depottntent of the county
61.Inner easing/tubing-length(if!mown); (ft.) where abandoned..
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6g.Screen length(if known): (ft.)
Form GW-30 North Carolha Deptrlmcol of Environment and Natural Resources-Division of WaterResontecs Revised Awn 2013

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WELL ABANDONMENT RECORD' For Internal Use ONLY: I
This fair can be used for single or nlrtlliplewells. I
I.Well Contractor information: WELL ABANDONMENT DETAILS .
Robert Miller 7a.Number of wells being abandaned: 1
wen Cotyrne9or Name(orfullnursep:rsanall}aliando',Nguell,onhiaihcrpropcn}) For rriu&tpk hJeetton or issn-wartlr IIsarpl2. wells ONLY with the wane
cYirurrttcoai•libundai wit,purr eons bnar'bne rrn.
NC Wdl Contractor Coo Ifcndoti Ma ter 71s.Approximate tvdume of►rater staining in well(s): - (gal.)
it
SAEDACCO FOR WATER.SUPPLY WELLS ONLY:
• Couq cot?Name
7u Type of disinfectant used: 1 I .
2.Wel1Construction Permit+i:, , W10100704 _ i
L1.tuRopldii4le well permits 0.e.Coauh:.Sa ie,Yarinrce.L;erGurr,.eh:l libeler, 7d.rluiountuf disinfectant used: •
3.Well use(chedtwell use): - - ;
Water Supply Well: ' 7e.Sealing materials:used(cheek all that apply): .
❑Agricultural • - - Ohltinicip,31/Ptlblie. ❑Neat Ccmcnt.Grout ' ; Dl Bcntonite Chips or Pellets.
❑Geothcrrnal(Heating/Cooling Supply) DResidential Water Supply(single) ❑•Sand Cement Gout i• ❑DryClay
Ohultistrial/Comntcrcial EIRcsidentiat Water Simply(shared) ❑Concrete Gram- I i ❑Drill Cuttings •
❑irrigation _ - . . El Specialty Groul ' I ElGravel
Ron-1VatcrSupply Well: —` _-._
❑Bentonite Slurry . •I El Other(explain under 7g)
UMoaitorhig . pRet oveiy
Injection Wcll: - • - 7f.For each material selected above,provide amount of:titaterials trct.d: .
❑Aquifer Recharge DGniundw-,uer Renicdititimr • i
•
DA'quifcrStomge and Recovery ElSalinity Barrier . ' !
Bentonite.:251b ,Wtr:gal.
❑AguiferTest . OSlonnwaterDratnage _,i .
❑E.perinteutal Teehnoloev .❑Subsideike Control
7g,Ptttvtdc a brief description of the ult:rndmmncnt procedure: •
DGeolltertnal(Closed Loop) ❑Tracer ' 1,
. Pulled tooling and abandonedjiborehole w/ granular bentonite.
OGeothermal(Heating/Cooling Return) ❑Ot ertexplaire under 7a} - I t__- -• - -- -...,,
2/28/24
•
4.Dafcwell(s).abaruloncd: _ - i MAR" i ?
Sa Well location: I:I 2024
Zboyovski Property . . +. I : 5''0.A''4'•'�a .1R
Facility/Orvn:r Name Facility Ina(ifapplkablc}
S.Certification: Dt�dt ��
•
146 Smokey- Park Hwy. Asheville, NC 28806 2/28/2024
Physical Address,City,and Zip 5i�rgtu�.e .,7:.r;bt;,;: .'St�' ?`.• ,ir'rt:r Dale
Buncombe 13y signing this fins, 1 hereby certify flit al the wars)r)wac(trerej abandoned in .
County Parcel likaaifiditimiNo.(PIN) accordance with 15. .br.C1C 02C.0109.ur2C.0200 Well Gofistntclion Stanrkrrd
• and that a copy ofll:is record has bear provided to the ti•e11 outer. •
Sh.l ltihtde and longitude in degrees/Minutes/seconds or decimal degrees: I i
(if well trrcld,ow)4u/lnag is sollidea) 9.Site diagram or additional well details:
You may use the back of this page to provide additional Well site dixails-or Well
N %V _abattdoimleitt Aetails.•You may also attack additional pages if necessary.
.CONSTRUCTION DETAILS OF WELD'S)RUING ABANDONED• $URMITTAT.iNSTRUCTtONS
Made hell coriarnetion tncurel(s)if available. Fir multiple iMecrite rin or n•watir supply 1
Hells ONLY with the s env ruroueum'aben r,AaitMem.ion con vibmtt.tmeArlit 10a.,For All-Wells: Submil this forts Within 30 days of.completion•or well
abandonment to the lbollowing:
. 63.Well l O l:H-1
Dayisirin of WutcrResnntrcts,Information Processing Unit,
33 .I617 Mail Service Center;Raleigh,NC 27699-1617
6h.Total well.depth: A)
1Uh.Forth lecllon Wells: In addition to sending the form to the address in [Oa
6c.Borehole dlatncter:l•5 (in.) above,also submit one copy of this form Within 30 days of'completion of well
abiuulomneut to the following:
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Division of Water Resources,Uudei'ouud ihijection Coutavl Progratu,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,italcigh,NC 27699-1636
1 1
6e.Outer easing length(if!mown): • (ft.) the
Fnr Water Snnnly&itriectton Weilsi Its addition to sending the form to
the addresses) above, also submit one copy of this font:within 34 days of
completion of well abandonment to the county health depiinnteni of the county
'6f.Inner easing/tubing length(if)mown): (ft.) where abandoned.
6g.Screen length(If known): (ft.)
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Farm GW-30 Nonh Carolina Department of Environment and Natuctl Resources-Division of Water Rom p s i Revised August 2013
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WELL ABANDONMENT RECORD FerlmernalUseONLY;
This feint can be used forsinele or multipte wells
1,Well Contractor information: •WELL ABANDONMENT DETAI11S1
Robert Miller • \ 7a.Number urArdlsbeingnhnndanld15
Vt'clrC ntmclor.None(ornUtonr persanally.:dmmfonlnyscllanlisnterpropcny) Far multiple Infection, or rroimraterrFi,supply. wells ONLY 'with the. sane
cmartnrariorr/abaedoitment,irm eausailvn)t wr I ftr7n;
11 2675-A
• MC Well ContradorCeniftcatioii Narita•• '711.Aljprgzrmate volume of watts•rent lining in*elks): - {gaU •
•
sAEDACCo • FOR WArRSurpLY WELLFOR WATTAISUPFLY WELLS ONLY:
CoarpanyNatnc •
7e.Typeo6disjnfectantti±red: . : I • . •
2:Well Construction Pct•ndt ll:, , WI0100704 '
List all apldtitable well permits(i.e.Carriii pale,:Parirrnxe.Il jtlrtlarl N1Cl f t'swwtl 1'
7d.Autoun t of disinfectant-uswt:
3.Well ustl(chcdcwdl use): .
Water Supply Well; 7e Scaling m;tteriplsused(chcc[;all 1D t apply):
lJtlgricultatat • • 17Mtinicipal/Public , ❑Neat Cement Grout I till Bcntonite•Chips or Pacts
• pGeotlicnntl(Heating/Cooling Siipply) 17itesti:kra)tl W,aterSupply(single) '❑Sand•Cenrertt Grn_ut ❑thy Clay
❑hidu5trial!Commcrcial ❑Residential Water Supplys(shared) Elncr Concrete Grout. • 1 d Dtitl Ciltdngs •
❑litigation d Specialty Grout - I El Gravel
Non-Water Supply Welt: . ❑Bentanite Slnrty El Other(explain under 7g)
•
EMonitorine Eget:ovety
• injection Well: • . - 7f.For cacti material sd_cetcd'aboct:,;pro%ide amount Of.nititeiials used:
• I:Aquifer.Reciarge �GrouitdwaterRentediation .
[]Aquifer Storage and Tiecov ety DSalinity Rattier '
Bentonite.:251b ,Wtr:gal. !,
ClAguiferTest ❑Stonmvater.Dnliiiage
DEtgtstimental Teehttotog ❑Subsidence Coattrrl • • f 7g.Provide a brie dcseriptian Of the:ill aritionment procedure:
ElGeodieflnat(Closed Loop) . ❑Tracer !' I'
Pulled tooling and abandoned;boreholes WI granular ,
OGeothenual(Heating/Cooling Return) .• ❑Other(explain under 7g).. . . •
bentonite. a fb -' T+„
,,. - '�r t.. ,. 1r'
4.Date well(s).abandoaed.2/28/24
Sa,-Wdl location: ;,•IMAr� ! ��24
lntr `r en 7._Zboyovski.Property 8.Cer1ikatioit: I, 1 Dv., ,:f"-,
.4 UnaFact triowntr Nam Fadlity IPA(ifapplicablcl 1 • rCYB 196 Smokey Park.Hwy: Asheville, NO 28806 _ lj 2/28/2024 - •
Physical Address.City.and Zip Si n.reor,;,.•F:`•;'�:•lt�:,':;s�!st *nr r pare. I
Buncombe _ 13y signing 110s farm,1 herby certify Mitt the wilts)was(were)abandoned in
Couinty' Paid ldenll0 trims No.(PINj nc.erdrrdce ivitlt 1541:'CAC 02e.0100i'11r;2C.0?00 iVell Conan ation Standards
and thin a copy ofilris record hat been pprorided to the well rimier.
Sb.Latitude and longitude in degrecenrinnOifSeeandsordecintardcgrccess • • ' •
Orwell field,one Leong is rattrtcicty) 9.Site diagram or additional well details:
You t use ti►e•back of this page to:>rovide additional VivaVivasite.details or hell
• - N - • • • - W uay.abandoiuttem details..You alio.attacl'L additional pages if ttecessaly..
. CONSTRI1CTION DETAILS OF WELL(Sl BEING:ABANDONED SUBMriTAL.INSTRUCTIONS t ' •
:ttlad,.irtl cvnt'iractlart recvrd(s)if aoirrilable. For multiple Oyertleueor rian•a•atu•supply ' -
. eltsONLY tritli sire avnI •rstrractiom'ahoirthmrrern.ieu eansulutal cure form 10n:Far All'Wells:' ,Submit•this tom[Ittithin 30 days'of completion of well
Ga Wclt :A-1 - A-5 abandonment to the following: -
Diiision of Water Resaurets,Iiinformation•Prucessing Unit,
Gb.Total well depth: 33 (Ills} .1617 Mail Service Cente'r,Raleigh,NC 27699-1617
10h.F r In lee'ion Wells:'In addition to1sending the form to the address In tOe
6c.Borehole diameter;l•5 (• above,'also submit one copy of this form within 30 days of completion Of Well
abandonment Collie following; I'
Gd.Water rev el bctove ground surface: (ft.) Division of Water Resourers,Underground injection Control Progrittu,
1636 Mail Service-Center,litaleighi NC 27619-1636
Gc.Outer cnsitrgit n�,Qlr(Klmnr'n): (fL) 10e.For Water-Snarls.•&ii,icrtinto WOIL In addition to.sending the form to
the address(es) Owe.'oho submit one copy of this form within 30 days of
' completion-of well abandonment to the-annoy health department of the county
where abandoned.
61.Inner ensin�g(tuhing length(iflmuwn): (FL) •,
6g.Street]length(if Iniotvn): (ft.)
FaintGW-30 NonhCarolimDcp timecaofE,wironutcntandNaturalRcsou_sees-Envision of Water Moms Revised Aqua 2013