Buncombe_Well Abandonment_20240617 (6)

WELL ABANDONMENT RECORD Forinocrn:flVwONIY
This fonn can be used for single of mtdtiple wells
1.Well Cantracmr Information: \\'ELL.ABANDONMENT DETAILS
Rich Lemire 7a.Numlter of wills being,abandoned: 1
Well Cotaraaor Nana oar well uwtai prsanally atsvdottutg well on lus9ar proper 1 !,o- ,nrrinplc otle,Iran v ,wnraafer stgrpl, -ell, ONLI, rrrh the same
c'rNl<frpa'fMM Nh,YN�rY1FurMf:1r,M tr0/whtl1N.Nte firrm
2593A
NC Well Namt,rr
7h.Approximate tolurne of water remaining in%rIIodV0NF (Ral.l
Cantanctor Cettificatian
SAEDACCO FOR N ATF.R SUPPI.I \\FI,I_S ONLY:
cane aq Naar 7c.T}pe of di.infe tans used:
2.Will CovatnKtioe Permit
fasr,dlnpp/ku le well prrmor n.e.(vent.,Shoe.(ananre brfeltum,e1c,,fknnw,r
d. \mount of JisinPiytant uxtil:
J.Will use(check:wtd ale)-
Water Sapplh We•11: 7e.Scaling material.used(chmi,all that appN):
❑Agncuhurak ❑Municipal Public 0 Nr-fl Cement(imut 01 Bcdonitc Chips or Pellets
OGeothemral Mcaung;'C•oohng Supply) Dltcstdcnnal W'atcr Itupph (singicl ❑ Sand Cennent Urout ❑ Dn Clak
❑lndustrial,Commerctal ❑Rcslderanal%VatcrStrp(th(stared) ❑ Comwic Grout ❑ Dail Callings
❑Im tutu ❑ Spayalh Grout ❑ Gra%cl
Non-Water Supply Well: I 1 Bentcnute Slum I_l Other(explain under 7p
I➢INonttonng ❑Recos'en
Injection Well: 7f,For each material st�leacd Allow.pro.ide amount of material law-4:
DAgwierRechrrge ❑GrounduwerRemediatton Neat Cem. :941b ,Wtr:6gal. Sand Cem. :lb ,Wtr:gal.
❑Aquifer Storagc and Rene»cn ❑SAIIIHh Barer
PORTLAND /BENTONITE POWER/BENTOI
❑Aquifer Teat ❑StommaterUra(nttgc ------ --
OExVennieatal Technologn ❑subsideme C•on uel -g.Pr,n idc a brief Jcsrripunu of t he abundnnuu nt It cc du e
DGeothemtal(Closed Loop1 LITracer
D milm al(Hearin g'Coolin Return) f lOther(explain under 7 ) BENTONITE PELLETS SLOW RELEASE TO TOP OF WATER,THEM TREMMIE
GROUTED TOP OF WATER TO St7R5 Fi _
1.Date adl(s)It4aadptred: 5-14-2024 ti, R
Sin.Well location: JUN 1 7 2024
FORMER ALLIANCE CAROLINA TOOL/MOLD CO.
t':wilm ",1.r 8.Certification: IRMFfRTRfAi4+i Trref M1�!$
� QwCY�Ni
125
Glenn Bridge Rd. Arden, NC 28704 —F/Mv�Gi 5/19/2024
Phcsical Addre.- - i Wen Ow•tter Draw
BUNCOMBE B) -iRnrrrs(this fixm• I he-by eerftA,that the well(s) was(were,ahmicAoned in
(o 114r P,r,.l Ir1;m,t:..rt.:n�.. .Pl\, .,rco►rlatx-e with 15.4.'vCAC(!.Y'.I11(M!or Y- Q.V0 ff-e11 Cohshachun Standards
and drat a cap)•of this record has been provided to the well owner.
Sk Latitude and longitude in degyrrslminutevscconds or decimal drxrrcs:
Orwell field ota Ott Wig t,,olluutti: 9.Site diagram or additional well detaAe:
You out the the back,of this plg,:to pro de addmontal well site details or well
« abacdonnteru details. You tim also attach additional pages if narssan.
CONSTRUMONDEI.AII..>OFµEI_taSl Ill IN(, kB%\D0%tD SI'BMMALtNSTRUCTIOYS
.!Math eei!1r12r1rL(1KMr renn.ba r/a,wl ar W h.,r mate sapph'
N,rll<ONLY with the mmir t Wrstrwfum atrfOtl/tllMl,t71L IW can submt tale htrnt Ina. For All \\'ells: Sohniii this forth within 30 dBys of completion of well
net.\\ell I1)g:ME-3 :iNudoument In the follmink;
Die ision of N ater Resources,Information ProcessinK Unit,
Nl•lt depth: A)25 1617 Mail Sen ice Tenter,Raleigh.M•2 764Y)-1617
611. Ialdl
lab.For Imitction Wells: In addition to sending the fonn to the address in I0a
nc.Rr,nhnlc dianxter:2 aiwsc. also submit one cu of this foot widen 10 daps of completion of well
lin,) cup} of
I the following;
nil.N etc, Let rl brill,) ground wrfaar: 23 ( ) Di%Won of Water Rcs,aorcr,,I adeMround In jt•ction Control Pntt;ram.
ll 1636 Mail Senice Q enter.Raleigh,NC'27699-I6J6
lite. For Water Suonh & Iniection bells: in addition to sending the form to
nc.Outer casing Icn--th of lino»n): ( ) Ilk :ddress(es( abo%e. also submit one cop, of this form with(( 70 days of
completion of will abandonnocut to the:ours health department of the count%
w hcrc abondoncd
n(.toner rasin�'hobing length OfI:nawnl: ttM.)
ng.Screen Icagnh(if 6nown r A)
Fan,GW-10 Nonh C'arohrn iktunnan of Ern tromoara add Naturrl Pesowccs-Di%gslon of 14'atef R.-iouxV-s Pei sed Augua 201z