Buncombe_Well Abandonment_20240617 (5)

WELL ABANDONMENT RECORD IOT11nrrn:fl'. 4 ONI!
This form can be used for single of multip6e wells
1.Well Contractor Information: W'E1.1.ABANDONMENT DE:TAII S
Rich Lemire 7a.Number of wells being abandoned: l
Well lbn eraUW Nane for vLdlo%nLf peRonalls Aunikining%ell on het her rforiefIN 1 tiO mulnple• 0gV0110, ,w 1010-0(40' q,f l/1 .r;l: a%1V v/N1 the dWnt'
r,N,•Flit,n,/nlfhrokkAnsuent,taw tcew.wthlnit,me h,rm
2593A
7b.A
NC Well CotaraaorCenilicativa Number ppn)vimatc vulntfre of w attti•mrmyining in tncll(-,PONE (Ipl)
3AEDACCO FOR W ATER SUPPI l W FLLSONLY:
Catpan)Nam C.1}Ise of disinfectant used:
2.Wdl Comtr action Perth III:,
fw,dl,WpIkohh-w•ed pvrnntr n.t,.Cuiirm..`hme.J ur;w e• ImeLlitim e1c.,of kiw In Id. .kmininl of dis)nfeCtanl u%ed:
3.%'ail use(check.N ell use1:
Rater Supply Will: 7e.Sealing materials used(check:A that apply'):
❑.•k_n:ultuml ❑Nlumicip v uhh: 3 Neat Centeno Grout all Bcatonitc Chips or Pellets
❑(icothcnnal(Hcating C'oolmt.Supply I ❑Rcsidettud Water Supph Isingicl ❑ Send C•enfert Grout ❑ Dn CUN
❑ItditsinalrCommercial ❑Resfderttal Water Strpph fshated) ❑Concrete Grout ❑ Drill Cutntip
❑Im'•tiou ❑ Specialq Gtutu ❑ Gravel
Nun-Water Supply Well: U Bervouite Slum I I Other(ecplanl under 7•gn
NNIonuonne ❑Recovrn
Injection%'ell: 7f.For each material w•lected above.provide amount of materials ofied:
❑Agwkr Recharge ❑Gtourdwater Remediatnont Neat Cem.:941b ,Wtr:6gal. Sand Cem. :lb ,Wtr:gal.
❑Agmter Storage and Rctirn en ❑Salitih flamer
PORTLAND /BENTONITE POWER/BENTO]
❑Aquifer Test ❑Slonimater Drainage -- ---
❑ENpennncntal Techntologn ❑Subsideme Control T
r.Pnnride a brief drscriptirm of he ahandnnux•nl procedure:
OGeothenital(Closed Loop) ❑Tracer
BENTONITE PELLETS SLOW BET-EASE TO TOP OF WATER,THEM TREMMIE
OGeothemvd(Heatin Coolie Return) DOtherIc\ ,tin under 7ul _
GROUTED TOP OF WATER TO SURFACE.
4.Date well(%)abandnncd: 5-14-2024
Sit.Well htcalion:
FORMER ALLIANCE CAROLINA TOOL/MOLD CO. ttwet.r.v.rtc+: �'�r�1nt1�A ufq
8.C!/llflcaflall:
F.xilm(h,,,r . ,�• F.w:Om me�u ��t,�sabkl �+:>�Ks
125 Glenn Bridge Rd. Arden, NC 28704 '+1 � 5/19/2024
Pfts sical Addre.. Srf¢Wttre of :died Won Cotutac tsw or Wen 00 act Dolt
BUNCOMBE Ill'mgmeig Nits frnt. I henebv cero/v that the weH(s)was(wemi dltwWu red in
C•ouw.� I'n.c1 1J 11111 a(ton NO.1PINI ncconlance wills 114:,VC4C 0217,4100 or X 02t90 Weil Canstswciton Vimcllartls
and that a crypt of this record Jars beer#prov)ded to the well owner.
Ali.I atitufle and Itrngitfidt in degrceslminuirv%cconds nr drivimal degrectu:
stl n ell field.ore Lit king t..nl(tctctt t 9.Site dialtram or additional we*dteMNs:
You tivo use the bac),of this page to prrnYde additional well site details or%l ell
N W' abatdounvem details. You etas also atach atldnitinal pages if ntecessan
CONSTRUMON DETAILS OF WTUAS)BEING ABANDONED SUBMTTT.•si.INSTRUCTIONS
Alimh wrl/cr,arlrLclr+.a n•n,n!•. ,7 a,wf,e,h 14r mulnpk nytc#trr#or port-tt>Na,col+I it
welkONLY with the cattsnhmIwwek*W Isla. For All 'Activ Sulinut this form within ?0 dais ofcongrletron of well
6a.We6 UWMW-2 Axi dcnntem In the following
Division of Water Resource,Information ProctssinK Udt,
lutnl ell depth: (fl.)
40 1617 Mail Smice Center,Raleigh.NC 17699-1617
n,lr, w
IUb. Fur Inloctiom W Is: In atttlilion to sending the foml to the address in IOa
above. also sublml one CYIp\ of this fomt within 10 dm.s of completion of well
n,c.Rtu,hole liana ter:2 (in.) abarionnicm to the 161lowukg
Division of Water Rmurce,,Underground and Injection Conlrel Program.6d.Ware#level nelnw ground surt'aee: 27 (fk) 1636 Mail Sen ice('enter.Raleigh.NU 276"-1636
Irk.For Water Suonav & Inkctwtn Wells: In amiliou to sending the foml to
fie Outer casilir IcnLrh(if know nl: (h j the address(eat atim e. also subnmt otk cop% of this form within it) days of
completion al'well abardnnnint to the comn heahh tlepanme#t of the count♦
v%befc abandoned
61.hmcrcasinV'tabinL IcnLKh(if l:nawui: (fl.l
it-,.Screen IcuLih rd'know n(: (ft.)
Fomt GW-3ft Nonh I.atoltto Depunutar of Em nroontent and Naturrl Resotures-Dh ision of Water Rsouk%cs Re.tied August 20I