Buncombe_Well Abandonment_20240429

...---- - �_.._..�.�.�-.- --��...v .y jForinternaljjse ONLY: 1 • -- ---- ""1.:--,"-: Di,
1.Well Contractor Information: WELL ABANDONMENT DETAILS *•,:
N',5 or\ ` 7a.For Geoprobe/DPT or Close d;Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: I '
NC Well Contractor Certification Number 76 Approximate volume of water remaining in well(s): No (gal.)
Q I'
1�e) Set1i1'04- ` IN_ ' FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: ektturare.
2.Well Construction Permit#: Jba 4' QOO 4
List all applicable well construction permits(Le.UIC,County,State,Variance,etc)ifknown
7d.Amount of disinfectant used: a \-0-Ao3
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
DAgricultural ❑Municipal/Public 0 Neat Cement Grout I 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry
❑Monitoring ❑Recovery ❑Other(explain under 7g)
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 4 (bast, re. ,�
❑Aquifer Storage and Recovery OSalinity Barrier
s L I
❑Aquifer Test ❑StormwaterDrainage P •T col-GVGTG ; 2-
❑Experimental Technology OSubsidence Control
7g
❑Geothermal(Closed Loop) OTracer Provide a brief descriptionof the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 1)//n- ket 1 t DwGl c L' 3/4 wash smile.
}� a, I C +� Z i 1,r,' ,� t 1T! 10 We.It • �YiLS�t�ei, P (t?t3'� pcdr4-i�
4.Date well(s)abandoned: v..
APR 2 2024 Italti.1 svr ce'
5a.Well location: Q
M1' C,bo.e 1 esernSk Zr try v r's;l:r,n Pr r.cr. ±U� ^
-
Facili Facility/Owner Name `"'^'^ / 1
t!' Facility 11�(�appliCatile) 8.Certifi lion: � J
5 t4:1� t O:rd 'Tv \, to ile vitjj,JUG428136 .�--- t DA a' ui
Physical Address,City,and Zip n Si turn of Certifi mhactor er t
e
a t f C4 "ram q Q- (S� I T2 / �"` Bysigning thisform, I here
St► S hereby:per*that the well(s) was(were) abandoned hi
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record htis been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
,3 ". 5 Lk b%b e N Ira• 3 91' c a 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
Attach well construction record(s)ijavailable.Formultiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
t Division of Water Resources,Information Processing Unit,
6b.Total well depth: / (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 •
410b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 36 (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 46 i (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-16?
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Inieetion Wells: In addition to send
address(es)above,also submit one copy of this form within 3t'
of well abandonment to the county health department e
6f.Inner casing/tubing length(if known): (ft.) abandoned. ! ,
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources