Buncombe_Well Abandonment_20240617 (8)

WELL ABANDONMENT RECORD For lnkmill-acONIY
This form can be used for single or multiple wells
1.We8 fnntr actor IOOorniatiOe: W'ELI.ABANDONMENT DETAIL 4
Rich Lemire 7a.Number of wells being!abandoned: 1
Well Cottuaxwv Naar lot well owner pemamllr atunkrang well on hr Iker propen)I Fw mrrinJrlr rArermnr .o• ,Fan-«area rt,pldv relli OrVLI vtrh The aatn,
c,.n•rrrr,-tllAn,nsomk,nmrnr,rrra rrar,-nlvatr low IF,rm
2593A
7b. 1lrpru�irneh rulurawofwaarrrmainingmwc11N1�ONE Igal.l
NC WcllComrwinrCcnir"lionNnnihct
SAEDACCO FOR W A I FR SUPPLI'W EI.LS ONLY:
ConVem Name -c.Ti,pc of disittfeetatr used:
2.W'dl C"A.vctbn Pcrrdt N:,
Lardlrgyrkrehle well pvrmN.rn.e.tlwnn.Stime.ldnwac Lr/t,hnw,rti.iiJk,mvn
d. lruuunt nl ili.inllvtAnt ux•d:
J.%'ell u.w(chcd<well use):
Water Suppl} well: 7e,Sealieg ttattcrial.s used tchcrk Al that apply):
OAgrwultural ❑%ltuvclpal�Pllhhc 3 Teat Ccmcrit Grout M Hcntonitc Chips or Pcllcts
O(icothcrroal tHcatvng,C oohng.Anvls I ❑Rcsidcivt:d Water Supph Isingic) ❑ Sand C•ensent Grout ❑ Dn Cla,.
❑IrdusnnaL(•omnercmI ❑Residctvt:d Wafer Snpph Isharrd) ❑ Concrete Grout ❑ Drill Cuttings
❑hog twii ❑ Speaak Grout ❑ Gray el
Noe-Water Supply Well: I.I Hclacnute Slum I i(hher Iei,platn tltdcf 7g)
s klointorng ❑Rccoc cn
Injection Well: X For each material wlected Ante.pnicidr amount of materiata uw`d:
❑Agmfcr Recharge ❑Cimundualer Rernodlalton Neat Cem. :941b ,Wtr:6gal. Sand Cem. :lb ,Wtr:gal,
❑Agwfer Storage aid Recoven ❑Sahruh flamer
❑Aqui(Cr'11est ❑Slonmsater Uratnaage
PORTLAND /BENTONITE POWER/BENTOI
OE\pcnntcnml Technolo_n ElSubmdelrce C'oivrul 71t,Preside a brief description of the abandonment lmoctdure:
OGertherI/Closed Loopl ❑Tracer
0GeothtmtallH(stin Coolib Rodlre L101herles ainundc�7 ) BENTONITE PELLETS SLOW RELEASE TO TOP OF WATER,THEM TREMMIE
GROUTED TOP OF WATER TO SURFACE.
R
i.Datewdllslahendnmdc 5-14-2024 ��� L .
sa.Well hrcation: JUN 1 7 2024
FORMER ALLIANCE CAROLINA TOOL/MOLD CO.
Facilm(hurl# Facility f0N(if applic*lcl S.Certification: w4wxViiI4rl P-�w-r0�t6 )UFA
125 Glenn Bridge Rd. Arden, NC 28704 --Q/Wsri.-ice 5/19/2024
Ph%sical Addle— c Slguvlttne daf. :tied We11 CrimlacMr or Well Chc mr Date
BUNCOMBE fit•vignoig then Jivm, l hereby certrA,that Me well(s) was rwerel mbmtduned in
C'oanh Parcel Idemlfcalton No.(PIN) adx-ordance with ISA?CAC 02.0I00 or X7 0.'r00 Well Canvhvction ltandurds
and That a copy of this record has beer#provided to the well ou ner.
5b.lagitudc and longitude in deVrrvlminutca/scaands or decimal ftmes:
lit well fold one kit>liwg I,..nit¢vn 1 9.Site diagram or additional wc41 deta07:
You nun tee(lie back of this pap.-to p"de adtbItonal well Site details Or well
N W' abardonmem details. You nac also attach additional pages if necessary.
CONSTRII(TION DETAILS OF W FWS1 BEING ABANDONED SUBMITTAL INSTRUCTIONS
.Ht,xk aril runclru�)nnt mm,,rd—N a,whANe. Por malople oyecnen ev rain-rrvt,7 sapph
Neil.,O.yf.t rr,/A ter oe mor cwr.rrs,rfume aA,rnk)wvnvciw con submil,ure kwm. l0a. For All W'e1b: Subimt flu% form within 30 dtn-s of complelwn of aril
6a.W'cY ID#t•
MW-5S ahatdonnicni in the folhouing
Division of W Ater Resuurcm.Information Processing l 1 nit.
hb.Tot.tl well depth: 34 (fr,)
1617 Mail Senice Center,Raleigh.NC 27699-1617
10b.For Infection Wells: In addition to sciduag like form to the address in Ina
above-also subittil one copy of this form within 10 dons of completion of well
t.c,Rirrrhnlc dianxler:2 Ile► abardonniem to the follommi-
DWsloaof WaterRenounc:,,Cndcrunound Injcrdun Coninol Program.
1,41.N rtcr level below ,.roand uIr•faee: 24 (flu.) 1636 Mail Scrsice Center.Raleigh,NC 27699-1636
loc- For Water Sum)h fi InicIlain Welht: In addition to sending the fornl to
he.Outer ca>irivk-n--nh(of knownI: (ft.) Ilk ;iddress(es1 abonc. also sliOmoi otw cup} of this fora within In cims of
completion of well abandrnuncnt to lie cower leabh department of the couun
u f cre ah i Boned
6f. Inncrcasin�'hibin;:Ien�Kh(ifknnwn): A.)
tog.Scorn Icnl:11i(if knoo ii c ((f,l
FourGW-ant Non hCarolina DepannicmofEmoronnicia and Naiural Rewinces-Dhisionof RaterRcsoarces Rc%osed Aupsm 1)13