Buncombe_Well Abandonment_20240617

WELL ABANDONMENT RECORD 1.rlrM•n,al l ON N
This form can be used for single or multiple Hells
1.Well Cantractnr Information: WELI.ABANDONMENT DFT ULS
Rich Lemire 7a.Number of wells being shandnned: l
Wdl('„tvima r Nana tot%dl wAim pemomlh abardotung wan oit ht;rlier praperts t Flo. moir+rd, ouvt1"." ,v ,p fn la•,' 'upoh retie DNLI wGd+ 1 k. ..».,.
"I'Mrm,rn r+, ,irelrwm.an,i.,k tm,++lwur ww hwnl
2593A
III.Approximate rubome of w ater remaining,m well(sIPOME (xal.►
NC Well CerimcrarCcrrifictwirm Nrtwttcr
SAEDACCO
F(llt%N XrYRSUPPIA %FLISONLY:
Couyan)Name -, 1 N I„ of diu"It-ftam
2.Wdl Cetlstw don letwtk 0-
1-jo and,tppfkvhk well pereatr(i.e.Cm an.Nh,oc. l o,w k< brr,tioe��e�tJlbaure
-,1. *mount of disinftstant ux^d:
J.Well use(chc&well use):
Water Supply Will: 7e,Scaling n►aterials used(cheek all that apply):
❑Agricultural ❑klunkipaUPuhlic X Neat Cenicm Choral X Aetwonac Chrpc or Pellets
O(rnthcrinal(Heaturg"Ctxiltn_supply) ❑Residential Water Supph isinglc) ❑ Sand Cerrcrw Grout ❑ Dry Clay
01ndustnal'Commcicial ❑Rcsidenital Water Supph Isharedl ❑ ConC(ereGrout ❑ Drill Cuttings
Dlm •lion ❑ Specialty Grout ❑ Gras el
Nan-Water Supply Well: 1_1 Bervenite Slurn L]Other*explain under 7gj
OgMonuomw ❑Recosrn
Injection Well: H Far each material`elected alw%e.pnoidc anumni of materials III":
DAgmttrRecterrgc ❑CiroundwaierReniedt:riton Neat Cem.:941b ,Wtr:6ga3.. Sand Cem. :lb ,Wtr:gal.
DAgutfu Storage and Recce cry ❑Saluuty Ramer
DAgurfrr lest ❑Slorrmater Drainage ___ __ PORTLAND /BENTONITE POWER/BENTOI
DExpetrmcnial Teclmolog-x OSubmdetce C'otitul - I'r,it Idea brief Ile,cripr,ut of the ahandtmment litoct-dure:
DCrcothemnal(Closed Loop) DTracer
DCxolhermal INeahn ootl Retum) 00dwt ain under 7 gt BENTONITE PELLETS SLOW RELEASE TO TOP OF WATER,THEM TREMMIE
GROUTED TOP OF WATER TO SURFACE. s
1.DAtcwcll(s)Abrn�doncd: 5-19-2029 ,i—;` ,
Sa.W'ell Itrcatins: JUN 17 ZOZ4
FORMER ALLIANCE CAROLINA TOOL/MOLD CO.
pP X.Ccilificalion: � P,y3�r^f,1M rf+
1'.ailrlt fin rue V:nr.- 1-,.•I-i. lh uta Itiabk. y
uAk
125 Glenn Bridge Rd. Arden, NC 28704 _.�of.,� .ii a 5/19/2024
-..... -- - - ........ .._ 4:ia
Phs sical Address.C'n, c Saynuwe of :ilicd Well Comoaar or Wen Owner Dare
BUNCOMBE By'Sighing rhos form, 1 hereby certify that the well(s) was(werer abwrdoned in
acx•onkmv with/.1.4.VCAC Oti.0100 or:(- (120()Well Camhucoon Vcindtmlr
and that a cvMr of this record Attu been provided io the well owner.
3b.Latitude and Inn%itarlc in deVresvminutrs.saeonds nr decimal degn'tTs:
ur Well fcki(ita hat krnp K,rtti,l:V11 9.Site diagram or Additional well detANr
You nUn use the back of this page to prtn ale:ddmonid well Mite details or well
N W' abandotimcm details. You nay aLo:ilach additional pages if nocnsan
I Rl ( I ION DETA11 s OF NVEL S)BEING ABANDONED SUBMIWAL INSTRUCTIONS
Jnml,drk'. ha.nn+ihple Injecrxm ri-rem-water swpphl
weih 0ALY w+tti the u~,vmInkrkwr nhwkknm+,m!-tun,an whwif~Iwm [Ga. For All Wets: Submit Ibis fomi within 30 days of completion of aril
6A W+er HW:MW-1 abandonment to the following
Disision of Water Rauurrm.Information Pnrccvsing t nits
blr.Total well depAr. tf6)
44 1617 *fail Senice Center,Raleigh,NC 27699-1617
Job.Fur talection Wcilst In atililion to sending the Conn to the address in 10a
abMe. also subntil one copy of this form nuhw UP days of completion of well
6e.FG,rrholc diameter:2 Iin.► abandonnicut lu tie tollottimc
23 Ili%Won of Rater Resource%,Cnderstround Injection Coninil Pntgram.
arrr kwd hel/rr Brotati sfrefarae: (ft) 1636 Mail Srrsice Center.Raleigh.NC 27699-1636
lac. For Water Sunnis &For Water & Iniatiiio r Wells: In addition to sending the form to
(wc Outer casing length lif*.nowN1: (1L) llw addrt-sslesl abo%e. also submit ote Cop} of this form within 30 dms of
conipleion of isdl abandonment to the counts health depanrrxn of the corrm
sclerc ah andotrcd
6f.Inner casing''tnbin_ktitynh lif ivowa): ([t.)
1-1.Semen length(if Loon"I: (h l
Foim GW-30 North Carotin Depanmcet of Ens uottnanl a+d Natural tic wiCcs-Dls ision of Water Resources Rc,-,cd 4ugusi 24,t+